Management of the Apical Third

The greatest enemy of truth is very often not the deliberate, contrived and dishonest, but the myth persistent, persuasive, and unrealistic. We enjoy the comfort of opinion without the discomfort of thought. John F. Kennedy

How We Manage the Apical Third

Does it matter?

Apical Third Histology

Historical Concepts
The CDJ as a dividing line is imaginary (Coolidge, 29) Canals should be filled to the CDJ (Skillen, 30) Canals should be slightly overfilled (Blayney, 27)

Apical Third Anatomy

Classic Concept

Kuttler 55

Reality
Dummer 84; Ainamo & Le 68 Madsen et al 00; Meder et al 09

Kuttler JADA 1955 (A myth?)

Apical Morphology of Maxillary Molars Using Microcomputerized Tomography

Meder-Cowherd L, Williamson A, Johnson W

In Preparation for Publication, J Endod 2010

Materials and Methods

Shape of apical canal anatomy determined Generated micro-computerized 3-D images Analyzed maxillary molar palatal roots Selected images giving best view of apical canal Analyzed by trained and blinded evaluators Determined shape of apical canal anatomy Categorized into configuration groups

Results

Apical anatomy highly variable Several shapes of apical constriction

Parallel 35% Single 18% Tapering (Classic) 15% Flaring 18% Delta 12%

Anatomy of Structures in the Apical Region of the Canal

A Histologic Evaluation

Frequent deviation of foramen from apex

R. Madsen L. Baldassari-Cruz R. Walton

(Abstract) J Endod 2000

Materials and Methods

Results

Teeth and apical tissues removed from cadavers Histologically prepared Longitudinal sections to include apical 1/3 of canal Determined were:

Apical Constriction

Frequently not present When present, shape and canal level variable

Cemento-Dentinal Junction

Location of apical foramen, apical constriction Anatomy of apical constriction Relationship of CDJ with apical constriction

Levels highly variable Difficult to interpret

Comparison with Kuttlers findings and diagram

No specimen matched Kuttlers diagram

Multiconstricted

Flared

Apical anatomy often altered because of apical pathosis and root resorption

In Summary:
Kuttlers concept diagram likely does not occur When present, the apical constriction is highly variable Frequently, there is no constriction There is no clinical technique to evaluate presence of constriction or shape of apical anatomy The apical constriction should not be used as a landmark for C&S or obturation

Apical Canal Anatomy

The apical few millimeters is variable in shape in cross-section Many apical canals are flattened (ribbon-shaped) May be multiple foramina Frequent deviation from apex
Gani & Visvisian JOE 1999 Wu et al OOOOE 2000 Soma et al IEJ 2008 Martos et al IEJ 2009

Ganni and Visvisian 99; Wu 00

Apical Canal Structure

Marked variations Accessory canals, resorptions, repair, pulp stones, irregular secondary dentin Cementum-like tissue on canal walls

Apical Third Histology

Classic Concept Reality

Mjr et al IEJ, 2001

Aberrations in the Apical Third

Frequency Can

Lateral Canals
Frequency Can

they be debrided? Can they be obturated? Does it matter?

they be debrided? Can they be obturated? Does it matter?

Frequency and Location

Frequency high Most in posterior teeth Predominance in apical 1/3

Degerness and Bowles J Endod 2008

Apical Delta

Can Lateral Canals be Obturated in the Apical Third?

Canals prepared then obturated with Schilder technique Roots were cleaned Very few lateral canals filled with gp and/or sealer

Venturi et al IEJ 36:54, 2003

Are Lateral Canals and Apical Ramifications Debrided and Filled?

Apparently not Teeth with RCT extracted Roots prepared histologically LCs and ARs examined for tissue, obturating materials and bacteria Results: LCs and ARs not debrided and seldom contained obturating material
Ricucci, Siqueira. J Endod 36: 1, 2010

Does It Matter If Lateral Canals are Debrided and Obturated?

Intracanal Isthmi
Frequency Can

Apparently not Block sections of apical regions in root-filled teeth were examined in cadaver jaws All roots had lateral canals No lateral canals contained obturating material No relationship was detected between unfilled lateral canals and the status of inflammation at the periapex

they be debrided? Can they be obturated? Does it matter?

Barthel, Zimmer, Trope. J Endod 30:75, 2004

Apical Patency
What is it? What is the technique based upon? What are the advantages? What are the disadvantages?

How will small patency files behave?

Patency File and Apical Transportation

#s 10, 15, 20 and 25 patency files Precurved SS and NiTi hand files Files used sequentially Transportation seen with each file size

Goldberg & Massone J Endod 28:510, 2002

Effect of Maintaining Apical Patency on Canal Transportation

Compared different preparation techniques

Lightspeed rotary with and without patency files Balanced force hand with and without patency

Results:

All techniques produced transportation No difference between groups

Tsesis et al IEJ 2008

Apical Patency: Other considerations?

Post-treatment pain?

No effect

Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy. JADA 2009 For endodontic procedures: Manipulation beyond the apex is not recommended

Arias et al J Endod 2009

Success rate?

Not determined

Tissue damage?

Not determined,

however

Apical Patency in Summary:

Has no biological rationale Likely

Aspects of Apical Third Preparation

Apical

does not accomplish the stated objectives damages periapical tissues does not improve outcomes

Clearing

Has no effect on postreatment pain

Size

of Preparation

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Does Increased Enlargement Reduce Bacteria and Improve Debridement?

Bacteria in the apical third

Yes

Tan & Messer. JOE 2002 Card et al. JOE 2002 Usman et al. JOE 2004 Baugh & Wallace. JOE 2005 Heish et al. IEJ 2007

No (when initially to a larger size)

Coldero & Saunders. IEJ 2002

Oval Canal

Necrotic Debris

Before

Round Canal

Clean and Ready for Obturation

Apical Clearing

After

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Apical Clearing Procedure Effectiveness of Apical Clearing: Histologic and Morphologic Evaluation
Parris J, Wilcox L, Walton R J Endod 20:219, 1994

Final apical preparation (enlargement)

Irrigant present in canal Files 3-4 sizes larger than MAF rotated at WL Canal irrigated Canal dried with paper points Largest file rotated at WL

Final apical reaming (Dry Reaming)

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Possible Advantages of Apical Clearing

Maximize debridement Deeper penetration of irrigating needle/solution Increase size of apical preparation Improved obturation

Objectives
Compare effectiveness of step-back without apical clearing vs. stepback with apical clearing for:

Debris removal and walls planed Apical transportation

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Conclusions
Apical clearing resulted in better debridement Apical transportation was found in both groups; more in the apically cleared group

Why is there minimal transportation?

What About the Smear Layer?

What About Apical Preparation Size?

Studies generally favor removal NaOCl alternated with EDTA best Deep needle penetration Special irrigating devices? Apical third less predictable removal
Messer Uroz-Torres et al. J Endod, 2010 Violich, Chandler. Int Endod J, 2010

R Madsen

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Mesial root - 1 mm from apex

Root Canal Treatment
Looks Good? Length OK Shape OK

necrotic tissue and debris

Why did it fail? Let Lets extract and section--section--Courtesy Dr S Senia

Mesial root - 2 mm from Apex

Distal Root - Foramen

Poor obturation

Distal Root - 1 mm from Apex

Distal Root - 3 mm from Apex

Canal not instrumented to the correct diameter

Necrotic Tissue and Debris Necrotic tissue and debris

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Working Length Considerations

Prognosis Periapical

Response Post-treatment Symptoms Systemic Impact

Nair R. In: Pathways to the Pulp 2006

Considerations
Prognosis Periapical

Prognosis
Extrusion

of Obturating Material
An irritant Related to decreased success

Response Post-treatment Symptoms Systemic Impact

Nair R. Pathways of the Pulp, 2006 Torabinejad & Siggurdson. Endodontics: Principles and Practice 2009

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Determining Optimal Obturation Length: A Meta-analysis of Literature

Short of the radiographic apex had better success than long Preferable to err on the short side than be long (uncertain about sealer extrusion only)

Schaeffer, White, Walton. J Endod 2005 Evid Based Dent 2005

Prognosis Long-term Studies Show:

Optimal result: end preparation and obturation within radiographic apex Too short, success rate drops Beyond apex, an even poorer result

Prognosis

Success rate of endodontic treatment of teeth with vital and nonvital pulps. A meta-analysis

Gutmann & Witherspoon, Pathways to the Pulp, 8th ed. 2002

No difference between vital and non-vital pulps Failure rate greater with a lesion present Success much lower with obturation overextension than with flush or underextension Conclusion: The root canal should be filled to within 2mm of the radiographic apex.

Kojima K et al. OOOOE 97: 95, 2004

Considerations
Prognosis Periapical

Tissue Injury and Inflammation from:

Instruments Irrigants Medicaments Obturating

Response Post-treatment Symptoms Systemic Impact

Materials

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Termination of Preparation and Obturation

Short

of the radiographic apex Short of the apical foramen

Review: Ricucci, Langeland, Int Endo J, 1998

Termination of Preparation and Obturation

Vital pulp: 1-3 mm short Necrotic pulp: 0-2 mm short

Wu, Wesselink, Walton OOOOE 2000

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Techniques of Canal Preparation

Standardized Flaring

Debridement of the Apical Third

Hand tends to debride better than rotary Apical canals are variable in shape Uninstrumented, undebrided areas are common Ahlquist et al IEJ, 2001

Stepback Crown-down

Rotary

Barbizam et al JOE, 2002 Wu & Wesselink IEJ, 2001 Rdig et al IEJ, 2002

Shaping of the Apical Third

All techniques tend to transport Factors (curvature, size, shape) are important Different instruments and techniques cause variability

Peters et al J Endod, 2001 Imura et al J Endod, 2001 Ahlquist et al Int Endod J, 2001 Hartmann et al J Endod, 2007 Moore et al Int Endod J, 2009

Obturation
Length Technique

Cold Lateral Warm Vertical Other

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Tissue Reaction to Obturation

Short

Extrusion of Debris

of the apex little response Beyond the apex

Inflammation Delayed healing

Compared NiTi rotary (Lightspeed & ProFile .04) and stainless steel hand (step-back & balanced force) Determined amount of debris extrusion All techniques produced apical debris Overall, NiTi rotary extruded the least

Ricucci & Langeland, IEJ, 1998 Guttmann & Witherspoon, 2002

Reddy S & Hicks L. JOE, 1998

Considerations
Prognosis

Post-Canal Preparation Symptoms

Response Post-treatment Symptoms Systemic Impact

Periapical

Canal preparation with either SS hand or NiTi rotary Determined pain levels and pain incidence No difference in the groups

Aqrabawi J et al. J Dent 2006

Post-Obturation Symptoms
48% reported symptoms after obturation 10% or less significant symptoms Overfill (no lesion) more pain

Considerations
Prognosis

Response Post-treatment Symptoms Systemic Impact

Periradicular

Harrison et al. JOE, 1983

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Systemic Considerations
Oral

Microbes and Disease

Bacteremia

Inducing Bacteremia

Factors that produce bacteremia

Necrosis Over-instrumentation

Impact

Bacterial Extension
Pulp Necrosis Apical Foramen

Overinstrumentation and Bacteremia

Periradicular Contamination

Short Close Beyond

Gutierrez et al., 1999

Intracanal Bacteria in Blood

Bender et al, Oral Surg, 60 Baumgartner et al, JOE, 76

Debelian and Tronstad, 1998 Ayub et al IEJ 2007

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Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy. JADA 2009 For endodontic procedures: Manipulation beyond the apex is not recommended

In Conclusion

Conclusions (continued)
Lengths should be 1-3 mm short of the apex Aberrations are inconsistently debrided Debris in the apical canal preparation should be reduced before obturation Apical canal preparation should be at least #40 There is no superior instrumentation technique

Apical canal anatomy and histology are variable and indeterminable, clinically Instruments, materials and chemicals should be confined to the canal

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Periapical Tissue Injury and Inflammation Occurs from:

Instruments Irrigants Medicaments Obturating

Termination of Preparation and Obturation

Vital pulp: 1-3 mm short Necrotic pulp: 0-2 mm short

Materials

Termination of Preparation and Obturation

Short

Bacterial Extrusion Beyond the Apex Will Produce:

of the radiographic apex of the apical foramen

Periapical inflammation

Short

And May Produce:

Systemic disease

Finally
We

need more definitive information based on:

Scientific data Evidence-based research Outcomes assessment

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Good clinical decisions require scientific accuracy to avoid bias Clinical significance is the consideration of risk vs. benefit Important outcomes (success) of therapy are measured by a combination of evidence-based criteria, clinical judgment and common sense.

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