Clinical Research
Evaluation of X-Ray Projection Angulation for Successful
Radix Entomolaris Diagnosis in Mandibular First Molars
In Vitro
Qian Wang, MD,* Gang Yu, MD,* Xue-dong Zhou, DDS, PhD,† Ove A. Peters, DMD, MS, PhD,‡
Qing-hua Zheng, MD,* and Ding-ming Huang, DDS, PhD†
Abstract
Introduction: The aim of this study was to evaluate
the radiographic features of permanent three-rooted
mandibular first molars with radix entomolaris (RE),
investigate the correlation between anatomical classifi-
cation and radiographic type of RE, and to determine
the most effective horizontal beam angulation for
the diagnosis of RE. Methods: Twenty-five extracted
mandibular first permanent molars with RE were selected
for taking radiographs in 7 horizontal angulations. By
using set criteria, 3 evaluators assessed morphologic
and radiographic features of the RE and optimum beam
angulation for RE diagnosis. Intraexaminer variability
was analyzed with Cohen kappa test. Results: Three
types of curvature of RE presented with 3 distinct types
of typical radiographic appearance on orthoradial radio-
graphs. We classified the radiographic features of RE
into 3 types, as follows: type i, type ii, and type iii. Seven
teeth showed type i radiographic features. Zero-degree,
5-degree, 15-degree, and 25-degree radiographs were
significantly better than the mesially angulated –15-
degree and –25-degree images for detecting the type
i RE images (P < .05). Fifteen-degree, 25-degree, and
–25-degree horizontal beam angulations showed signifi-
cantly more accurate diagnoses of RE in 8 type ii images
(P < .05). Only 25-degree–angled radiographs were found
to have a high diagnostic yield of type iii RE images (P <
.05). A significant correlation was found between
morphologic and radiographic types of RE (P < .05, contin-
gency coefficient = 0.473). Intraexaminer variability was
low, with kappa = 0.68 (P < .05). Conclusions: RE
presents 3 types of typical radiographic features on
orthoradial radiographs. Additional 25-degree mesial
horizontal-angled radiographs are essential for preopera-
tive identification and evaluation of RE, especially types ii
and iii. (J Endod 2011;37:1063–1068)
From the *State Key Laboratory of Oral Diseases (Sichuan University), Chengdu; †Department of Conservative Dentistry, West China College of Stomatology, Sichuan
University, Chengdu, China; and ‡Department of Endodontics, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, California.
This work was supported by funds from Key Clinical Project from the Ministry of Health of China (2004-468). The funders had no role in study design, data collection
and analysis, decision to publish, or preparation of the manuscript.
Address requests for reprints to Dr Ding-ming Huang, Department of Conservative Dentistry, West China College of Stomatology, Sichuan University, Chengdu,
China, 610041. E-mail address: dingminghuang@163.com
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.05.017
JOE — Volume 37, Number 8, August 2011
Key Words
Anatomical variations, mandibular first molar, radiology, radix entomolaris, root canal
T he success of root canal treatment depends on thorough mechanical and chemical
cleansing of the entire pulp cavity and complete obturation with an inert filling
material. To achieve this goal, it is imperative that the clinician has a detailed knowledge
and adequate preoperative assessment of the root canal morphology of each individual
tooth being treated.
In the permanent dentition, the mandibular first molar has been considered to
assume maximum bite force and possess the most important masticatory function.
It is one of the earliest erupting succedaneous teeth, as well as one frequently suffering
from pulpal disease and apical periodontitis (1). Meanwhile, mandibular first molars
have complex root and canal morphology (2–5), and many studies have attempted to
assess their anatomical characteristics. It is now generally accepted that a major
anatomical variant of the two-rooted mandibular first molar is a tooth with a lingually
located supernumerary root. This variant was first mentioned in the literature by
Carabelli in 1844 and termed radix entomolaris (RE) (6); it refers to a distolingual
extra root, as opposed to radix paramolaris buccaly (7).
The prevalence of RE in mandibular first molars has been reported to be as low
as 0.68% in Caucasians, 3% in African populations, and as high as 40% in Mongoloid
populations (8–10). Various studies have shown that populations of Asians have a
prevalence of RE of 5.8% to more than 30% (11–13). We found in a population of
95 patients in a total of 350 cases (27.14%) that presented permanent mandibular
first molars with RE, 60.13% cases (95 of 158) had the fourth canal arising from RE
(unpublished data). Meanwhile, the dimensions of the RE can vary from a short
conical extension to a mature root with normal length and root canal, which are
curved buccolingually. The high prevalence and diverse anatomical configuration of
REs present endodontic challenges for clinicians (14).
Currently several techniques have been used to investigate the root canal
configuration, such as the transparent specimen technique (15), conventional radio-
graphs (12), radiopaque contrast media (16), cross-sectional cutting (17), scanning
electron microscopy (SEM) (18), micro–computed tomography (13), and cone-beam
computed tomography (19). Only a few studies have reported the morphology of RE in
detail. Carlsen and Alexandersen (7) described 4 types, according to the location of the
cervical part of the RE, with direct observation by the aid of the stereomicroscope. De
Evaluation of X-Ray Projection Angulation for Successful RE Diagnosis 1063
Clinical Research
Moor et al (14) classified REs evaluated from 12 clinically root-filled
and 6 extracted three-rooted mandibular first molars into types I–III
on the basis of the curvature of the separate RE variants in buccolingual
orientation. Most recently, RE was categorized into 5 types according to
their morphologic features by using three-dimensional images that were
reconstructed from cross-sectional computed tomography images
(11). Radiographic examination is the most common preoperative
assessment for root canal therapy, and different horizontal angulations
were sufficient for diagnosis of multiple rooted teeth to adequately
reflect the morphologic characteristics of the root canal system in the
third dimension (20). The optimum information provided by radio-
graphic studies requires sufficient anatomical knowledge of each tooth,
as well as an individualized beam projection for each type of tooth (21).
Little investigation has focused on effect of radiographic beam angula-
tion on interpretation of mandibular first molar root canal anatomy
(16); further research is required for the application of radiographs
to RE diagnosis.
Therefore, the present study aimed to evaluate the radiographic
features of RE at various horizontal angulations, to investigate possible
correlation between anatomical classification and radiographic type of
RE, and to determine the most effective horizontal angulation for
successful RE diagnosis in mandibular first molars.
Materials and Methods
Twenty-five mandibular first permanent molars (12 right and 13
left) with RE and intact contour, extracted from Chinese patients
attending various dental clinics within Chengdu, were selected for
this study. Patient informed consent and approval of the internal
review board had been obtained. The age, sex, and race of the
patients and the reasons for extraction were not recorded. Only teeth
with fully formed apices were selected. To remove the remaining soft
tissue or calculus on the teeth after scaling, teeth were placed in each
3% solution of potassium hydroxide and 75% alcohol for 48 hours
each.
The teeth were radiographed by using GENDEX dental x-ray
equipment (65 kVp, 7.5 mA, 0.26 seconds, Oralix AC; Dentsply Italia,
Milano, Italy) at the Department of Oral and Maxillofacial Radiology.
To mirror the paralleling technique in vitro (Fig. 1), teeth were held
on a wax base on the rotating table of a jig attached to a film holder
and beam-aiming device (22). A commercial angulometer with a point
Figure 1. Jig for standardized radiographic images.
1064 Wang et al.
was fixed on the base of rotating part of the jig to indicate the horizontal
angle of the x-ray beam. The buccal surface of the specimen tooth faced
to the tube. Kodak dental intraoral E-speed film (3  4 cm) (Eastman
Kodak Co, Rochester, NY) was exposed at various horizontal angula-
tions (–25 degrees, –15 degrees, –5 degrees, 0 degrees, 5 degrees,
15 degrees, 25 degrees); this refers to positive angles when taking
radiographs at mesial horizontal angulation and negative angles when
at distal angulation. A 26-cm focal spot-object distance and a 2-cm
object-film distance were used. These settings were determined in a pilot
study to produce the best quality radiographs.
All of the radiographs were assessed by 3 dentists with
endodontic experience. No time limit was set for assessments, and
the image sequence was randomized for the evaluators. The radio-
graphs were viewed on a standard viewing box without magnification
under dimmed lighting. The orthoradial (0 degrees) radiographs
were used to evaluate radiologic morphology of RE. Each morpho-
logic type of mandibular first molars was determined with 7 addi-
tional horizontal angulation radiographs to assess radiologic
angulations of developing distinct RE.
The number of visible canals and whether the RE was visible along
the entire length of the root were noted and tabulated. The following
criterion was required to diagnose the presence of RE: clear distinction
from a distobuccal root with distinct apex and continuous periodontal
space on radiographs. The evaluators were provided with the schematic
diagram as an aid to their judgments (Fig. 2). Any disagreement
between them was discussed until a consensus was reached.
Statistical analyses were performed by using SPSS (Version 13.0;
SPSS, Chicago, IL) software; the level of statistical significance was set at
P < .05. Intraexaminer variability was analyzed with the Cohen kappa test.
Results
Morphology of the RE
All REs were directly observed and categorized into 3 groups
according to their morphologic features (Fig. 3): type I, straight root
(6 cases); type II, coronal third curved and straight continuation to
the apex swung toward lingual (9 cases); type III, curvature in the
coronal third and buccal, especially mesiobuccal curvature from the
middle third to apical third of the root (10 cases).
Radiographic Analysis of the RE
On the basis of the radiographic overlapped degree between
distolingual and distobuccal root, the radiographic features of RE could
be classified into 3 types (Table 1): type i, slight overlapped image
(7 cases); type ii, moderate overlapped image of RE (8 cases); type
iii, severe overlapped image of RE (10 cases).
Figure 2. Schematic diagrams given to the observers.
JOE — Volume 37, Number 8, August 2011

Figure 3. Classification of extracted mandibular first molars with RE.
Analysis on the Correlation of Morphologic
Classification and Radiographic Type of the RE
As shown in Table 2, almost all type I REs present the type iii radio-
graphic features. Type II RE was detected in the majority of type ii RE
images, with a total frequency of 55.6% (Table 2). Type III RE was
detected most frequently (50%) in type i images, followed by in type ii.
There was a significant correlation between the morphologic and radio-
graphic types (P < .05, contingency coefficient = 0.473). Similarly, signif-
icant differences were obtained between the morphologic type (I, III) and
radiographic type (i, iii) (P < .05, contingency coefficient = 0.481).
JOE — Volume 37, Number 8, August 2011
Clinical Research
Effect of Different Horizontal Angled Radiographs
for the Diagnosis of RE
The results were shown in Table 3. Among 7 type i RE images,
0-degree, 5-degree, 15-degree, and 25-degree radiographs were
significantly better than the –15-degree and –25-degree images for
detecting RE. The diagnostic efficacy of –5-degree radiographs is
limited. Similarly, 15-degree, 25-degree, and –25-degree horizontal
beam angulations showed significantly more accurate diagnoses of
RE in 8 type ii images, followed by the 5-degree and –15-degree
images. Zero-degree and –5-degree radiographs did not detect RE.
Evaluation of X-Ray Projection Angulation for Successful RE Diagnosis 1065
Clinical Research

Figure 4. Representative images of various horizontal angulations of mandibular first molars with RE.

Twenty-five degrees is the most effective beam angulation for making
diagnosis of type ii RE images. In 10 type iii RE images, only
25-degree radiographs was found to have the highest diagnostic yield
of RE (100%) and the best horizontal projection angle to show RE. The
15-degree, –15-degree, and –25-degree images play a part in assessing
partial RE. The 0-degree, 5-degree, and –5-degree images failed to
identify the anatomy of RE.
Kappa test values for intraexaminer variability were greater than
0.68 (P < .05).
Discussion
Previous studies have shown a wide variation in the number of
canals and morphology of RE in mandibular first molars. According
to the pattern of their curvature, it was found that the majority of the
REs were type III with an additional curve starting from the mid-root
portion or in the apical third (14). In the present study, Type III REs
(40%) were found more frequently than the other anatomical types,
possessing an initial curvature in the coronal third and additional
buccal, especially mesiobuccal, curvature starting from the middle
third to apical third of the root. These morphologic classifications
offer an outline of the RE contours; however, they provide a limited
practical aid for the clinicians to discover and identify RE in
endodontics.
Clinically, radiographic examination is regarded as suitable
procedure for preoperative identification and assessment of RE.
Although the radiographic image is simply a two-dimensional repre-
sentation of a three-dimensional object, alteration of beam angulation
might provide additional information not readily available from the
orthoradial image (16). This information, gained before initiation

TABLE 1. Radiographic Features of Radix Entomolaris (RE)

Type of radiographic RE Overlapped degree
Type i (n = 7) An initial overlapping at the
coronal third or middle
third of the root canal,
continuation as a separate
root/root canal
Type ii (n = 8) A partial overlapping from
the coronal third to the
apical third
Type iii (n = 10) Full overlapping from the
coronal third to apical
third
Canal visible Image of RE
Two separate distal roots An identifiable radiographic
with distinct impressions image
of root canals
Two indefinite distal roots An ambiguous radiographic
with partially visible root image
canals
Indistinct radiographic An unidentifiable
sketch of distal roots with radiographic image
sudden discontinuous
image of middle third of
the root canals or with
a single root canal

1066 Wang et al. JOE — Volume 37, Number 8, August 2011


TABLE 2. Relationships of Morphologic Classification and Radiographic Type,
n (%), in Mandibular First Molars with Radix Entomolaris
Morphologic type
Radiographic type I (n = 6) II (n = 9)
i (n = 7) 0 2 (22.2)
ii (n = 8) 0 5 (55.6)
iii (n = 10) 6 (100) 2 (22.2)
Significant differences were found between the morphologic and radiographic types (P < .05, contin-
gency coefficient = 0.473). Significant differences were found between morphologic type (I, III) and
radiographic type (i, iii) (P < .05, contingency coefficient = 0.481).
of therapy, will greatly facilitate subsequent treatment. This study
drew attention to the radiographic features of RE with 7 horizontal
angulation radiographs, possible correlation between anatomical
classification and radiographic type of RE, and the most effective
horizontal angulation for successful RE diagnosis in mandibular first
molars.
On the basis of the radiographic characteristics of 25 REs on
orthoradial radiographs, we classified the radiographic REs into 3
types. Type i presents most identifiable radiographic images of RE,
which was found to have a high diagnostic yield on various horizontal
angulation radiographs, compared with types ii and iii. A large beam
angulation mesially or distally increased the probability of correctly
identifying the RE of type ii images. The majority of the radiographic
REs were type iii, and the ability to distinguish individual RE became
increasingly difficult because of overlapping of adjacent distobuccal
root. Multiple distal roots might appear to have only 1 fused cone
root radiographically, and thus clinicians might fail to recognize the
presence of RE on type iii radiograph perspicuously. Further analysis
showed a significant association between the radiographic and
morphologic types; especially morphologic type III RE was detected
most frequently in radiographic type i samples (P < .05), which sug-
gested that a high proportion of the identifiable type i RE images might
be mistaken for straight ones, or canals with secondary curvature might
be mistaken for canals with single curvature on orthoradial radio-
graphs. These unseen curvatures might account for loss of working
length during instrumentation; the enlargement of a canal with a prox-
imal curvature might result in severe canal transportation or strip perfo-
ration. These findings might provide clues to understanding
morphology of RE in mandibular first molars through radiographs
before endodontic procedure for clinicians.
Additional mesiodistal horizontal projections might help to
identify anatomy of RE, especially referring to type ii or iii radiographic
images of RE. The 25-degree horizontal beam angulation appears to
provide additional detail of RE not provided by any other angulations,
TABLE 3. Effect of Different Horizontal Projection Angles for Diagnosing Radix Entomolaris in Three-rooted Mandibular First Molars
n (%) 0 5
Type i (n = 7)
Correct assessment 7 (100)* 7 (100)*
Optimum diagnosis 0 0
Type ii (n = 8)
Correct assessment 0 6 (75)*
Optimum diagnosis 0 0
Type iii (n = 10)
Correct assessment 0 0
Optimum diagnosis 0 0
*Significant difference (P < .05).
JOE — Volume 37, Number 8, August 2011
Clinical Research
which is in line with previous studies that indicate 20 degrees–40
degrees is the most suitable beam angulation for detecting the number
of canals in one root (20, 23, 24). However, our results differ from
the study of Naoum et al (16), who suggested that 0-degree radio-
III (n = 10) graphs provided more information than 30-degree radiographs. The
5 (50) discrepancy might result from differences in sample sizes and
3 (30) methods.
2 (20) The present study found that 25-degree mesial radiographs
were significantly better than 25-degree distal radiographs for RE
visibility and determination of optimum diagnosis. Distal horizontal
angulation had little effect on diagnosing the RE, particularly when
a radiograph was taken from a small angle distally. The reason might
be that majority of REs are typically small, and conical roots located
toward mesiobuccal are moved toward the mesial, compared with
thick distobuccal root (11). According to Clark’s rule (also known
as SLOB rule or Walton’s projection) (25), an object that moves in
the same direction as the cone is located toward the lingual;
conversely, an object that moves in the opposite direction from
the cone is located toward the buccal. Consequently, the RE image
that moves distally is superimposed on the distobuccal root image
that moves toward the mesial, when taking radiographs with a small
distal angulation. We were unable to provide a correct assessment of
RE type, unless the radiographic beam came from the distal direction
at a large angle. Radiographs taken with eccentric beam angulations
have the potential to improve diagnosis, but they are inherently less
distinct. The images lose the normal sharpness expected from stan-
dard films because of anatomical structures (maxillary sinuses, nasal
fossae, zygomatic arch and anterior nasal spine or process, mental
foramen) that could overlay roots and affect visibility and identifica-
tion of roots and canals (26). Horizontal angulation might result in
blurring objects, which is directly proportional to cone angle. Image
distortion at the 25-degree distal horizontal angulation was evident in
this study (Fig. 3). These facts suggest that the 25-degree mesial
projection was superior to the 25-degree distal for assessing the
anatomy of RE. Because of the image distortion produced by altering
beam geometry, the noninvasive three-dimensional imaging tech-
nique, cone-beam computed tomography, might provide another
choice for further assessment (27).
Conclusion
RE presents with 3 distinct types of typical radiographic features on
orthoradial radiographs. Additional 25-degree mesial horizontal
angulation radiographs are essential for the preoperative identification
and evaluation of RE in type ii and type iii images. Knowledge of the
radiographic features of RE and optimum beam angulation for RE
diagnosis can be road maps to successful endodontics.
X-ray beam angulations (degrees)
15 25 –5 –15 –25
7 (100)* 7 (100)* 1 (14.3) 5 (71.4)* 7 (100)*
2 (28.6) 5 (71.4)* 0 0 0
8 (100)* 8 (100)* 0 5 (62.5) 8 (100)*
1 (12.5) 7 (87.5)* 0 0 0
7 (70) 10 (100)* 0 3 (30) 8 (80)*
0 10 (100)* 0 0 0
Evaluation of X-Ray Projection Angulation for Successful RE Diagnosis 1067
Clinical Research
Acknowledgments
The authors deny any conflicts of interest related to this study.
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