doi:10.1111/iej.
12508
REVIEW
Accessory roots and root canals in human anterior
teeth: a review and clinical considerations
H. M. A. Ahmed1 & A. A. Hashem2,3
1
Department of Conservative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia; 2Department
of Endodontics, Faculty of Dentistry, Ain Shams University, Cairo; and 3Department of Endodontics, Faculty of Dentistry,
Future University, Cairo, Egypt
Abstract
Ahmed HMA, Hashem AA. Accessory roots and root
canals in human anterior teeth: a review and clinical
considerations. International Endodontic Journal.
Anterior teeth may have aberrant anatomical varia-
tions in the number of roots and root canals. A
review of the literature was conducted using appro-
priate key words in major endodontic journals to
identify the available reported cases as well as experi-
mental and clinical investigations on accessory roots
and root canals in anterior teeth. After retrieving the
full text of related articles, cross-citations were identi-
fied, and the pooled data were then discussed.
Results revealed a higher prevalence in accessory
root/root canal variations in mandibular anterior
Introduction
A thorough knowledge of both root and root canal
morphology is a fundamental prerequisite for success-
ful root canal treatment (RCT) (Vertucci 2005). This
knowledge includes pre- and intra-operative aware-
ness of landmarks associated with normal morphol-
ogy as well as any aberrant anatomy of the root and
root canal system encountered in daily practice
(Vertucci 2005, Cantatore et al. 2006, Ahmed &
Abbott 2012a). A good understanding of the external
and internal anatomical features of the root would
Correspondence: Dr. Hany Mohamed Aly Ahmed, Department of
Conservative Dentistry, School of Dental Sciences, Universiti
Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
(Tel.: +60129857937; e-mail: hany_endodontist@hotmail.com).
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
teeth than in maxillary counterparts. However, max-
illary incisor teeth revealed the highest tendency for
accessory root/root canal aberrations caused by
anomalies such as dens invaginatus and palato-gingi-
val groove. Primary anterior teeth may also exhibit
external and internal anatomical variations in the
root, especially maxillary canines. Therefore, dental
practitioners should thoroughly assess all teeth
scheduled for root canal treatment to prevent the
undesirable consequences caused by inadequate
debridement of accessory configurations of the root
canal system.
Keywords: accessory, canine, central incisor, lat-
eral incisor, root, root canal.
Received 17 March 2015; accepted 9 July 2015
minimize the number of missed roots and root
canals during treatment, thus increasing the rate of
clinical success (Vertucci 2005, Cantatore et al.
2006).
Current knowledge on root and root canal morphol-
ogy is based on research findings and individual case
reports. Many clinicians perceive that a given tooth
contains a specific number of roots and/or canals.
However, careful evaluation of published material has
shown that variations in root anatomy are common
(D’Arcangelo et al. 2001). Maxillary anterior teeth are
well known to have a single root that usually encases
a single root canal; nevertheless, maxillary anteriors
with aberrant root/root canal anatomy exist (Lin et al.
2006, Kottoor et al. 2012). Similar deviation from the
normal anatomical features has been observed in
mandibular anterior teeth (Kartal & Yaniko
glu 1992,
Heling et al. 1995). Additional root canals that are
International Endodontic Journal 1
 Accessory roots and root canals in anterior teeth Ahmed & Hashem

not cleaned and filled may provide a source of persis-
tent irritation, thus compromising the long-term suc-
cess of RCT (Gondim et al. 2009).
This study attempts to correlate the potential occur-
rence of accessory roots/root canals in anterior teeth
with clinical practice. The aims are (i) to summarize
existing knowledge on aetiology and the prevalence of
accessory roots and root canals in anterior teeth, (ii)
to describe their clinical and radiographic landmarks
using conventional and contemporary examination
tools and (iii) to discuss the implications of such
anatomical variations on treatment procedures and
clinical outcomes.
Literature search methodology
An electronic search was conducted, spanning the
period from January 1970 to November 2014, to
identify investigations on accessory roots and root
canals in anterior teeth. Related studies and case
reports written in the English language and published
in major endodontic journals were included.
• Australian Endodontic Journal,
• Dental Traumatology (previously named as
Endodontics and Dental Traumatology),
• International Endodontic Journal,
• Journal of Endodontics and
• Oral Surgery Oral Medicine Oral Pathology (subse-
quently renamed as Oral Surgery Oral Medicine
Oral Pathology Oral Radiology and Endodontology
until December 2011).
The following keywords were used in the search:
1. ‘Accessory’ OR ‘Double’ OR ‘Extra’ OR ‘Four’ OR
‘Supernumerary’ OR ‘Supplemental’ OR ‘Three’
OR ‘Two’ AND ‘Incisor’ AND ‘Root’ OR ‘Canal’.
2. ‘Accessory’ OR ‘Double’ OR ‘Extra’ OR ‘Four’ OR
‘Supernumerary’ OR ‘Supplemental’ OR ‘Three’
OR ‘Two’ AND ‘Canine’ AND ‘Root’ OR ‘Canal’.
The papers which met the criteria described in
Table 1 were selected, cross-citations were detected,
and the data were then analysed. Tables S1–S4 sum-
marize the accessory roots and root canals in maxil-
lary and mandibular anterior teeth.
Terminology and aetiology
An accessory (also known as extra or additional)
root/root canal refers to the development of an addi-
tional number of roots/root canals in teeth compared
with that described in dental anatomy (Neville et al.
2002, Ahmed & Luddin 2012).
Accessory root formation usually occurs through
two ways, either by splitting the Hertwig’s epithelial
root sheath (HERS) to form two similar roots, or by
folding of the HERS to form an independent root
which may have various morphological features
(Ahmed & Abbott 2012a). Whilst the exact aetiology
of accessory roots is still uncertain, several factors
have been proposed, including different ethnicity, sev-
eral diseases and developmental anomalies, genetic
factors, local traumatic injuries and external pressure
(Kocsis & Marcsik 1989, Ahmed & Abbott 2012a,
Kang & Kim 2014).
An accessory root canal is a common finding that
occurs in the primary and permanent human dentition
(Vertucci 2005, Ahmed 2013). Ethnicity, age, develop-
mental anomalies and the formation of reparative den-
tine stimulated by external insults such as trauma,
caries, periodontal disease and restorative procedures
have been reported as contributing factors to the creation
of this anatomical variation (Neo & Chee 1990, Sert et al.
2004, Ahmed & Cheung 2012, Han et al. 2014).
Morphological variations
Accessory roots/root canals in normal anterior teeth (no
developmental anomalies)
Maxillary anterior teeth. The formation of root and/or
root canal aberration does not necessarily correspond

Table 1 Inclusion and exclusion criteria of the literature search methodology

Inclusion criteria Exclusion criteria

Anterior teeth that have
more than one root
Single-rooted anterior teeth
that have more than one root canal
Anterior teeth that have a single root and a single canal fused with a supplemental or
supernumerary tooth were excluded. Owing to the great difficulty in differentiating
gemination from fusion with a supernumerary tooth (Mader 1979, Kremeier et al. 2007),
gemination was also excluded
Common configurations (2-1 and 1-2-1) in single-rooted mandibular anterior teeth
(Walker 1988, Kartal & Yanikog
lu 1992, Sert et al. 2004, Sert & Bayirli 2004) were
also excluded

2 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Hashem Accessory roots and root canals in anterior teeth

to a similar aberration in the morphology of the
crown (Ahmed & Cheung 2012). A number of cases
document the presence of single-rooted maxillary
anterior teeth with two canals, or double-rooted max-
illary anteriors, with normal clinical crown compared
with the contra-lateral tooth (Hatton & Ferrillo 1989,
Lambruschini & Camps 1993, Reid et al. 1993, Gen-
ovese & Marsico 2003, Low & Chan 2004, Sponchi-
ado et al. 2006, Gondim et al. 2009). This finding
indicates the importance of careful radiographic
examination and intra-operative exploration of the
pulp chamber and canal system after access cavity
preparation.
Accessory roots and root canals in maxillary ante-
rior teeth may occur in a mesio-distal (Berbert et al.
1976, Furman & Wagner 1976, Thompson et al.
1985, Hatton & Ferrillo 1989, Collins 2001, Low &
Chan 2004, Sponchiado et al. 2006, Calvert 2014)
(Figs 1a and 2) or in a labio-palatal relation (Reid
et al. 1993, Lin et al. 2006, Gondim et al. 2009)
(Fig. 1c). The former type can be easily identified in
routine parallel periapical radiographs. However, the
latter type is more difficult to identify and usually
requires radiographs from different angulations (Kaffe
et al. 1985), or cone-beam computed tomography
(CBCT) views. Despite the importance of such different
radiographic views, proper intra-operative exploration
of the pulp chamber aids in locating such canals if
missed during radiographic interpretation (Ahmed &
Cheung 2012).
Root canal configuration type IV (2-2) (Vertucci
2005) is the most common accessory anatomical
variation reported in single- and double-rooted maxil-
lary anterior teeth (Table S1). Other configurations,
such as type (2-1) (Thompson et al. 1985, Al-Nazhan
1991) (Fig. 1c) and type (1-2) (Calvert 2014)
(Fig. 1a), have also been reported. Morphological
studies demonstrated a supplemental configuration
type (1-2-1) in both maxillary lateral incisors and
canines in Turkish and Chinese population groups
ß alisßkan et al. 1995, Sert & Bayirli 2004, Weng
(C
et al. 2009). Interestingly, Gondim et al. (2009)
reported a double-rooted maxillary lateral incisor that
had three separate root canals. Root canal configura-
tion type (1-3) may also occur in single-rooted maxil-
lary anterior teeth (Fig. 2).
Mandibular anterior teeth. Accessory roots and root
canals have also been reported in mandibular anterior
teeth, but these tooth types seem to exhibit more
complex anatomical variations than their maxillary
counterparts (Table S2). Numerous supplemental con-
figurations have been identified in different population
groups using methods such as staining and clearing
(Sert & Bayirli 2004, Sert et al. 2004) (Fig. 1e) and
microcomputed tomography (Milanezi de Almeida

(a) (b) (c) (d) (e)

Figure 1 (a) Periapical radiograph showing a maxillary left central incisor with associated periapical radiolucency (white
arrows). Accessory root canal [(type 1-2) yellow arrow] is identified in the distal portion of the apical third of the root. The
portal of exit is located in the mid-way of the periapical radiolucency. (b) Periapical radiograph showing a mandibular canine
having root canal configuration type (2-2). (c) Single-rooted maxillary canine that have a root canal configuration type (2-1).
(d) A sample of double-rooted mandibular canine. (e) A cleared mandibular incisor having two root canals with two separate
exits. An intercanal communication is observed in the apical third of the root (configuration type 2-1-2).

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 3
 Accessory roots and root canals in anterior teeth Ahmed & Hashem

(a) (b) (c)

(d) (e)

Figure 2 Maxillary central incisor with three root canals. (a) Preoperative radiograph showing maxillary left central incisor
with shorter root than contralateral tooth and apical periodontitis. There was no obvious shadow of the canal and the root
apex was broad. (b) With the aid of ultrasonics, two canals were located and hand files were introduced into the canals. How-
ever, they were not centralized. (c) Ultrasonics were used again deep into the root, and a third canal was located (patency was
established by a small K file). (d) A photograph showing the three canal orifices under a surgical microscope (13.69). (e) Post-
operative radiograph showing filling of the root canals using mineral trioxide aggregate.

et al. 2013, Leoni et al. 2014), as well as clinical
investigations using CBCT (Han et al. 2014). In con-
trast to maxillary anteriors, the frequent location of
such canals in a buccolingual direction usually com-
plicates their clinical identification using conventional
radiographs.
Root canal configuration types (2-2) and (1-2) are
the most common accessory anatomical variations in
single-rooted mandibular anteriors (Table S2) (Figs 1b
and 3). In contrast to maxillary canines, double-rooted
mandibular canines have been documented in a num-
ber of investigations (Hession 1977, Sharma et al.
1998, Mikrogeorgis et al. 1999, Versiani et al. 2011,
Han et al. 2014) (Fig. 1d), which may have three
canals (Heling et al. 1995). The occurrence of double
roots in mandibular incisors has also been reported
(Kocsis & Marcsik 1989, Loushine et al. 1993).
Identification landmarks
Preoperative assessment – clinical. Good anticipation
and proper observation of the coronal and radicular
landmarks are essential for the detection of accessory
roots/root canals. Anterior teeth that have accessory
roots/root canals may reveal a normal-shaped, but
relatively larger, crown compared with the contra-lat-
eral tooth (Henry 1970, Christie et al. 1981,
Michanowicz et al. 1990, Peix-Sanchez & Minana-
Laliga 1999). However, this should not be considered
as a general rule because accessory roots/root canals
can also exist with a normal-sized crown (Hatton &
Ferrillo 1989, Genovese & Marsico 2003, Low &
Chan 2004, Sponchiado et al. 2006, Gondim et al.
2009). In addition, the crown can be seriously dam-
aged (Thompson et al. 1985, Lin et al. 2006, Calvert
2014), restored, or the contra-lateral tooth may be
missing (Lin et al. 2006).
Accessory roots can be identified by probing of the
cervical root which may reveal bifurcations, especially if
accompanied with gingival recession (Ahmed & Abbott
2012a). The presence of an extra root may be associated
with the absence of mobility despite the presence of
remarkable probing depths (Genovese & Marsico 2003).
Mandibular anteriors with middle and apical root bifur-
cations usually cannot be identified by probing.

4 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Hashem Accessory roots and root canals in anterior teeth

(a) (b) (c) (d)

Figure 3 (a) Periapical radiograph showing a left mandibular lateral incisor scheduled for RCT. No break point or abrupt
diminishing of the canal was detected in the straight on radiograph. (b) The postoperative radiograph reveals extrusion of the
sealer into an empty space in the root indicating multiple communications with untreated accessory root canal (white arrows).
(c) The tooth was scheduled for another exploration, and the access was extended at the expense of the cingulum. A second
canal was detected (blue arrow). (d) Post-filling radiograph showing the two root canals. Each canal has a separate portal of
exit (yellow arrows).

Preoperative interpretation – radiographic. Despite the
inherent limitations of conventional radiographic
views which provide 2D images of 3D objects, good
quality preoperative periapical radiographs with more
than one horizontal projection aid in accurately
detecting root canal bifurcations and outline of the
periodontal ligament, thus facilitating the interpreta-
tion of internal and external root anatomy (Kaffe
et al. 1985, Ahmed & Abbott 2012a, Paes da Silva
Ramos Fernandes et al. 2014). Notably, increasing
the horizontal projection (≥40 beam angulation in
mandibular incisors) complicates the ability to detect
canals owing to overlapping of adjacent teeth (Klein
et al. 1997). In teeth with necrotic pulps, the pres-
ence of an apical rarefaction on the lateral side of the
root (Fig. 1a) or two periapical radiolucent areas
around the root surface may also suggest the pres-
ence of an extra root/root canal (Funato et al. 1998,
Lin et al. 2006).
Using magnifying devices or loupes during interpre-
tation of radiographs is beneficial as several details
may become evident once magnified. The application
of digital radiography provides an enhanced image
processing (Sanderink et al. 1994, Nair & Nair 2007).
Cone-beam computed tomography is a modern
diagnostic modality that may be useful when conven-
tional radiographs provide limited information and
further details are necessary (Han et al. 2014). Nowa-
days, many specialists dealing with complex cases
have the opportunity to evaluate CBCT images, and
in some cases, its use is essential to achieve clinical
success (Patel et al. 2015). The sagittal, coronal and
axial CBCT images provide 3D imaging with relatively
lower effective radiation doses than other CT systems
and eliminate the problem of geometric distortion and
superimposition of roots/root canals (Patel et al.
2007). The use of an operating microscope guided by
a previous CBCT image would be useful in treating
teeth with complex anatomical variations (Patel et al.
2015). CBCT can also be used as an educational tool
(Han et al. 2014).
Intraoperative identification. Complete removal of the
roof of the pulp chamber during access cavity prepara-
tion allows a full view of the internal anatomy of the
chamber. The configuration of the access cavity in
anterior teeth that comprise accessory roots/root
canals may show considerable variations (Sharma
et al. 1998, Low & Chan 2004, Maden et al. 2010). A
common reason for failure to identify a second canal is
inadequate access opening into the tooth which leaves
a lingual shelf of dentine over the second (usually the
lingual) canal (Kabak & Abbott 2007).
Careful visualization using magnification and explo-
ration of the pulp walls and floor can facilitate the
detection of accessory roots/root canals. Tactile
examination of the root canal walls with a small
pre-curved endodontic file can detect root canal bifur-
cations undetected during radiographic interpretation.

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 5
 Accessory roots and root canals in anterior teeth Ahmed & Hashem
A ‘catch’ on the way towards the apical foramen may
indicate the presence of an accessory canal orifice
(Ahmed & Abbott 2012a, Ahmed & Cheung 2012).
Other landmarks could be the eccentric location of an
endodontic file on a radiograph during working
length determination and inconsistent apex locator
readings (Thompson et al. 1985, Kabak & Abbott
2007). The presence of continuous bleeding in teeth
with a vital pulp despite complete canal instrumenta-
tion can also suggest the presence of accessory root
canals (Kabak & Abbott 2007).
Postoperative assessment. If one canal is left
untreated during mechanical instrumentation, the
additional canal can often be located after filling. Fill-
ing material (root canal sealer and thermoplasticized
gutta-percha if applied) can propagate from the filled
canal into the missed canal through intercanal com-
munications, if present, and appear in the postopera-
tive radiograph as a radiopaque line connecting to an
empty space (Fig. 3). Therefore, the outline of the fill-
ing material inside the root canal system should be
examined carefully after canal filling.
Endodontic management. In addition to the use of
well angulated, exposed and processed periapical
radiographs, an electronic apex locator would aid
determining the working lengths of these canals to
avoid procedural errors that may occur as a result of
the superimposition of files, especially when the
canals are in a labiolingual direction (Gondim et al.
2009).
Prior to mechanical instrumentation, evaluating
the morphological features, including the thickness of
the root dentine and canal curvatures, will assist in
selecting the most appropriate instrumentation tech-
nique (Gonzalez-Plata & Gonzalez-Plata 2003,
Sponchiado et al. 2006). The occurrence of double-
rooted anterior teeth that have small or thin roots
with abrupt apical curvatures as well as normal roots
encasing narrow canals has been reported (Heling
et al. 1995, Orguneser & Kartal 1998, Peix-Sanchez
& Minana-Laliga 1999, Gonzalez-Plata & Gonzalez-
Plata 2003). Thus, careful attention is required to
avoid undesirable consequences such as strip perfora-
tion caused by over-enlarging the canals or fracture
of endodontic instruments (Heling et al. 1995, Gonza-
lez-Plata & Gonzalez-Plata 2003).
The application of both cold lateral and warm com-
paction techniques is a valid approach for canal filling
of such cases (D’Arcangelo et al. 2001, Lin et al.
2006, Sponchiado et al. 2006, Calvert 2014). How-
ever, attention should be paid if warm compaction
6 International Endodontic Journal
techniques are to be used as these require more den-
tine to be removed to accommodate the heat carriers,
delivery needles and pluggers. Enhanced vision
through magnification and illumination is important
in controlling warm compaction procedures (Calvert
2014).
Accessory roots/root canals in anterior teeth caused by
developmental anomalies
Dens invaginatus. Definition, aetiology and morphology:
Dens invaginatus is a developmental anomaly that
results in an invagination of the enamel organ into
the dental papilla prior to calcification of the dental
tissues (Alani & Bishop 2008). The exact aetiology of
this anomaly is unclear, and many theories have
been proposed including growth retardation of a focal
group of cells, external forces, trauma, infection and
genetic factors (Alani & Bishop 2008). The prevalence
of dens invaginatus in individuals ranges from <1%
to >26% (H€ ulsmann 1997, Alani & Bishop 2008).
Oehlers (1957) classified dens invaginatus into three
types: Type I (most common) – is an enamel-lined
minor form that occurs within the confines of the
crown not extending beyond the amelocemental junc-
tion. Type II – is an enamel-lined form that invades the
root but remains confined as a blind sac. Communica-
tion with the dental pulp may or may not occur in this
type. Type III – is a form that penetrates through the
root perforating at the apical area showing a ‘second
foramen’ in the apical or periodontal area (no immedi-
ate communication occurs with the pulp). The invagi-
nation may be completely lined by enamel, but
cementum is frequently found lining the invagination
(Oehlers 1957). This anomaly arises most commonly
in maxillary lateral incisors and less frequently in
maxillary central incisors, mandibular anteriors and
canines (H€ ulsmann 1997, Alani & Bishop 2008)
(Table S3). The problems that arise in association with
this entity appear to be primarily related to the degree
of bacterial invasion along the invagination, which
can eventually lead to the involvement of the pulp
and/or periodontal ligament (Narayana et al. 2012).
Identification landmarks. Dens invaginatus type III,
and occasionally type II, may result in the formation
of double root canals [configuration type (2-2)]
(Table S3). Clinically, the crown of an affected tooth
may appear normal or have size and shape alterations
such as greater labio-palatal/mesio-distal diameter
and peg- or barrel-shaped teeth (Soares et al. 2007,
Bishop & Alani 2008). Radiographically, a blunder-
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Hashem Accessory roots and root canals in anterior teeth
buss opening of the invagination into the periodontal
ligament (pseudo-canal) is a characteristic feature of
dens invaginatus type III, whereas type II usually
appears as a tear-shaped loop into the pulp space or a
radiolucent pocket usually surrounded by a radio-opa-
que enamel border (Bishop & Alani 2008). 3D imag-
ing using CBCT helps in identifying the morphology
of the individual dens so that appropriate treatment
planning and treatment options, which must assess
the risk to benefits along with the patient preference
and compliance, can be selected (Narayana et al.
2012).
Endodontic management
Dens invaginatus with a normal pulp. Treatment of such
anterior teeth is dictated by the anatomical complex-
ity of each individual case. Reports of cases where the
two root canals (or one of them) are not involved in
the treatment exist in the literature (Greenfeld & Cam-
bruzzi 1986, H€ ulsmann 1997, Kfir et al. 2013). Selec-
tive treatment of the invagination is challenging and
resistant to instrumentation because of the enamel
lining (Soares et al. 2007). Along with the inconsis-
tent shape, rotary instrumentation is therefore not
recommended for use because of the increased likeli-
hood for file fracture (Bishop & Alani 2008). The
application of stainless steel (SS) or nickel titanium
(NiTi) files using reciprocation motion could be an
area for future investigations. Some authors speculate
that ultrasonic tips are more useful than SS and NiTi
endodontic instruments (Bishop & Alani 2008). Nota-
bly, applying ultrasonics requires adequate coolant to
prevent potential effects on the neighbouring vital
pulp tissues because of the heat generated during fric-
tion (Kfir et al. 2013).
Using an operating microscope in such cases has
proved to be a valuable clinical asset for the operator;
the microscope aids in the precise and sophisticated
execution of treatment techniques without compro-
mising the tooth structure (Jung 2004, Rodekirchen
et al. 2006). Thermoplasticized gutta-percha or min-
eral trioxide aggregate (MTA) (indicated when the
apical flow of the softened gutta-percha is difficult to
control) is often used for filling the invagination (de
Sousa & Bramante 1998, Kfir et al. 2013). Transpar-
ent 3D plastic models fabricated from CBCT data can
provide an effective guide for treating the invagina-
tion without jeopardizing the vitality of the pulp (Kfir
et al. 2013). Despite the high predictability of this
treatment approach, close follow-up and monitoring
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
is essential. If resolution does not occur, then consid-
eration may need to be given to RCT (Bishop & Alani
2008).
Dens invaginatus with an irreversibly inflamed pulp.
RCT of all canals is indicated when the pulp show
signs of irreversible inflammatory changes. This treat-
ment approach is associated with difficulty in locating
the rudimentary root canal because of the atypical
internal morphologic complexity (Walvekar & Behbe-
hani 1997, Kusgoz et al. 2009). Invaginations may
also restrict sufficient cleaning and shaping. Remov-
ing the central mass of the dens under magnification
is one option, especially if the root canals are in close
approximation to the invagination (keeping the
invagination and root canals separate in the apical
area is better to preserve the apical constriction) (Pai
et al. 2004). If this procedure is not applicable, then
copious irrigation using sodium hypochlorite is rec-
ommended to disinfect the root canals (Kusgoz et al.
2009, Kfir et al. 2013). The treatment of dens invagi-
natus type II is less problematic because the anomaly
does not extend to the apex (Rodekirchen et al. 2006,
George et al. 2010).
The application of calcium hydroxide as a medica-
ment between treatment appointments in these cases
is controversial; this medicament may be extremely
difficult to remove from such a complex space, thus
potentially compromising the effective obturation of
the invagination space (Kfir et al. 2013). Other
medicaments, such as Ledermix, have been suggested
as an alternative because it is easier to remove by irri-
gation; however, attention should be focused to the
staining potential of such medicaments in anterior
teeth (Ahmed & Abbott 2012b). The canals can be
filled normally, and an apical plug of MTA can be
used for filling the apical portion of the invagination
before applying thermoplasticized gutta-percha (Stef-
fen & Splieth 2005).
Other treatment protocols. A report described suc-
cessful management of a maxillary lateral incisor with
dens invaginatus, double canals and immature apex
via apexification using calcium hydroxide for
6 months, and the canal was then filled using the lat-
eral compaction technique (Jung 2004). Surgical
intervention (apicectomy followed by root-end filling
using either Super EBA, MTA or other materials) has
also been reported (H€ ulsmann 1997, Ortiz et al.
2004, S€ ubay & Kayatasß 2006, Soares et al. 2007). In
severe cases, extraction of the tooth could be the
treatment of choice (H€ ulsmann 1997,  Stamfelj et al.
2007).
International Endodontic Journal 7
 Accessory roots and root canals in anterior teeth Ahmed & Hashem
Palato-gingival groove
Definition, aetiology and morphology. Palato-gingival
groove (also known as radicular lingual groove or
disto-lingual groove) is a developmental anomaly that
is usually found on the palatal aspect of the root of a
maxillary incisor tooth. It usually begins in the cen-
tral fossa area, extends over the cingulum and contin-
ues apically down the root surface (Peikoff et al.
1985, Lara et al. 2000, Schwartz et al. 2006). The
prevalence of this anomaly ranges from <1% to 18%
(Kogon 1986, Lara et al. 2000, Sch€ afer et al. 2000,
Schwartz et al. 2006).
The aetiology of this groove is not fully understood.
It could represent an infolding of the enamel organ
and HERS or an alteration of genetic mechanisms
(Ennes & Lara 2004, Schwartz et al. 2006). Its pre-
dominance in the maxillary lateral incisors suggests
another possibility that the groove results from an
undesirable position of the lateral incisor during
development where it is surrounded by the central
incisor and canine that start initial calcification ear-
lier making this tooth germ highly susceptible to fold-
ing (Lara et al. 2000).
Despite the occasional occurrence of double-rooted
incisors caused by the palato-gingival groove, its clini-
cal implications are important because the groove can
lead to combined endodontic–periodontal lesions
(Sch€afer et al. 2000). The groove potentially provides
a pathway for oral microorganisms to penetrate into
the periodontal ligament tissues. When a breach
occurs in the periodontal attachment and the groove
is involved, a self-sustaining localized periodontal
pocket can develop along the length of the groove
(Schwartz et al. 2006). This inflammatory process
persists because of the potential communication path-
ways between the pulp and periodontal tissues (Peik-
off et al. 1985, Ahmed 2012).
Identification landmarks. Clinically, the operator can
identify the groove on the palatal aspect of the root
of a maxillary incisor tooth, together with its contin-
uation apically down the root surface, which may
correspond with a narrow periodontal pocket and
bone loss (Schwartz et al. 2006). The usual appear-
ance of the second root in a mesio-distal direction
facilitates its identification during radiographic exami-
nation. The root canal system of double-rooted inci-
sors having a palato-gingival groove shows
considerable variations (Table S4). Some authors
reported the successful detection of two root canals in
the main and accessory roots (Peikoff et al. 1985,
8 International Endodontic Journal
Greenfeld & Cambruzzi 1986, Gu 2011), whereas
others were unable to find a patent root canal space
in the accessory root even with 3D radiographic
imaging (Sch€ afer et al. 2000, Yavuz et al. 2008,
Gandhi et al. 2011).
Endodontic management. The treatment of double-
rooted/canalled anterior teeth with palato-gingival
grooves has not been evaluated in a controlled inves-
tigation, but multiple case reports describe treatment
modalities ranging from RCT of both roots/root canals
followed by periodontal treatment including curettage
to resection of the accessory root, odontoplasty and
application of autogenous bone grafts or freeze-dried
bone allografts and enamel matrix derivative (Sch€ afer
et al. 2000, Low & Chan 2004, Schwartz et al. 2006,
Yavuz et al. 2008, Gandhi et al. 2011). The applica-
tion of NaOCl at >3% concentration and ultrasonic irri-
gation may be beneficial (Low & Chan 2004, Schwartz
et al. 2006), especially if the canal is C-shaped
(Schwartz et al. 2006). In several clinical situations,
filling the cervical and mid-root portions of the root
canal system with a resin material or glass–ionomer
cement is preferred to facilitate odontoplasty of the root
groove (Schwartz et al. 2006). However, this procedure
would complicate root canal retreatment if indicated.
Association with other abnormalities
Fusion of a single-rooted anterior tooth with a super-
numerary or supplemental tooth would result in a
‘double tooth’ encasing two canals. A ‘double tooth’
is not discussed in this study (exclusion criteria –
Table 1); however, it appears essential to highlight
the association of anterior teeth that have accessory
root canals with such anatomical aberrations (i.e.
anterior tooth encasing more than one root canal
fused with a supernumerary tooth having its own
canal). Hosomi et al. (1989) and Peyrano & Zmener
(1995) reported the occurrence of maxillary central
and mandibular lateral incisors (encasing two sepa-
rate root canals each) fused with supernumerary
teeth (encasing one canal), respectively.
The association of double-rooted/canalled anterior
teeth with other abnormalities in the crown such as
enamel hypoplasia (Al-Nazhan 1991), dens invagina-
tus (Greenfeld & Cambruzzi 1986, H€ ulsmann & Hen-
gen 1996) and palato-gingival groove accompanied
with a talon cusp (Fabra-Campos 1990) has also been
reported. In some severe cases, the association of
abnormalities is difficult to interpret (Mangani & Rud-
dle 1994, Kottoor et al. 2012).
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Hashem Accessory roots and root canals in anterior teeth
Accessory roots and root canals in the primary anterior
teeth
Several reports have documented the occurrence of
accessory roots and root canals in the primary ante-
rior teeth at various levels of the root in children of
different ethnic groups (Barker et al. 1975, Chow
1980, Krolls & Donahue 1980, Morrow & Hylin
1993, Mochizuki et al. 2001, Dhanpal & King 2009,
Musale & Hegde 2010, Talebi et al. 2010, Cleghorn
et al. 2012). The concurrent existence of double-
rooted canines has been reported in both jaws (Ott &
Ball 1996, Mochizuki et al. 2001, Dhanpal & King
2009), but the prevalence of double-rooted primary
canines appears to be higher in the maxilla than the
mandible (Mochizuki et al. 2001). This finding is
opposite to that of the permanent dentition. The
occurrence of coronal and apical root bifurcations
indicates that the potential for developing supernu-
merary roots in the primary anterior teeth is present
throughout the course of root formation (Ott & Ball
1996). The double roots are usually located in a
mesio-distal direction, and they can be identified dur-
ing radiographic interpretation.
Orhan & Sari (2006) reported a double-rooted max-
illary canine that had three root canals identified
using staining and clearing technique. Musale &
Hegde (2010) documented the successful endodontic
management of a unilateral three-rooted primary
maxillary canine that had a normal crown morphol-
ogy. Notably, dens invaginatus may also occur in pri-
mary anterior teeth (Cleghorn et al. 2012). Given the
wide variations in the root and root canal anatomy of
primary anterior teeth and potential risks, clinicians
should undertake careful assessment and follow-up,
similar to that given to primary molars scheduled for
total pulpectomy procedures in order to ensure nor-
mal exfoliation and uncomplicated eruption of the
permanent successors (Ahmed 2013, 2014).
Prognosis
The ability to locate and treat accessory roots/root
canals and adequately treat the periodontal defect, if
present, ultimately determines the prognosis of these
teeth. Historically, teeth with severe types of dens
invaginatus and palatal grooves that exhibit moderate-
to-severe localized periodontal defects were deemed
untreatable or the prognosis of treatment was poor
resulting in extraction. To date, new treatment options
are available that provide better potential for retaining
these teeth (Yavuz et al. 2008, Kfir et al. 2013).
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Conclusions
The prevalence of accessory root/root canal variations
in mandibular anterior teeth is higher than maxillary
counterparts. Maxillary incisor teeth have the highest
tendency for accessory root/root canal aberrations
caused by anomalies such as dens invaginatus and
palato-gingival groove. Primary anterior teeth may
exhibit external and internal anatomical variations in
the root, especially maxillary canines. Owing to the
wide morphological divergence of the root and root
canal system in human anterior teeth, dental practi-
tioners should be aware of such anatomical variations
to minimize the risk of failure because of inadequate
debridement of inaccessible or undetected parts of the
root canal system. Modern diagnostic devices, recent
endodontic (and periodontal) techniques and current
advances in endodontic biomaterials could pave the
way for high levels of success in managing
such anatomical variations in the human anterior
dentition.
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Supporting Information
Additional Supporting Information may be found in
the online version of this article:
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Ahmed & Hashem Accessory roots and root canals in anterior teeth

Table S1. Summary of studies and reported cases –
accessory roots and root canals in permanent maxil-
lary anterior teeth (no developmental anomalies).
Table S2. Summary of studies and reported cases –
accessory roots and root canals in permanent mandibu-
lar anterior teeth (no developmental anomalies).
Table S3. Summary of studies and reported cases –
dens invaginatus in permanent anterior teeth that
have more than one root canal.
Table S4. Summary of studies and reported cases –
permanent anterior teeth that have palato-gingival
groove and more than one root canal.

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 13