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

Anatomy of Structures in the

Apical Region of the Canal

Apical anatomy highly variable

Several shapes of apical constriction
Parallel 35%
Single 18%
Tapering (Classic) 15%
Flaring 18%
Delta 12%

A Histologic Evaluation

R. Madsen
L. Baldassari-Cruz
R. Walton

Frequent deviation of foramen from apex

(Abstract) J Endod 2000

Materials and Methods

Teeth and apical tissues removed from cadavers

Histologically prepared
Longitudinal sections to include apical 1/3 of canal
Determined were:

Results

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

Comparison with Kuttlers findings and diagram

Apical Constriction

Levels highly variable

Difficult to interpret

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

Lateral Canals

Frequency

Frequency

Can

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

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

Frequency
Can

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

Effect of Maintaining Apical Patency

on Canal Transportation

Goldberg & Massone J Endod 28:510, 2002

Apical Patency: Other considerations?

Post-treatment pain?

No effect

Not determined

Tissue damage?

Not determined,

Has no biological rationale

Likely

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

Updated recommendations for managing

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

however

Apical Patency in Summary:

Arias et al J Endod 2009

Success rate?

Compared different preparation techniques

does not accomplish the stated objectives

damages periapical tissues
does not improve outcomes

Has no effect on postreatment pain

Aspects of Apical Third

Preparation
Apical

Size

Clearing

of Preparation

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Does Increased Enlargement Reduce

Bacteria and Improve Debridement?

Yes

Bacteria in the apical third

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

11

Apical Clearing Procedure

Effectiveness of Apical
Clearing: Histologic and
Morphologic Evaluation

Final apical preparation (enlargement)

Parris J, Wilcox L, Walton R J Endod 20:219, 1994

Irrigant present in canal

Files 3-4 sizes larger than MAF rotated at WL
Canal irrigated
Canal dried with paper points

Final apical reaming (Dry Reaming)

Largest file rotated at WL

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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

Why is there minimal transportation?

Apical clearing resulted in better

debridement
Apical transportation was found in
both groups; more in the apically
cleared group

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

Canal not
instrumented to the
correct diameter

Distal Root - 3 mm from Apex

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

Response
Post-treatment Symptoms
Systemic Impact

Prognosis
Extrusion

of
Obturating Material
An irritant
Related to decreased
success

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

Gutmann & Witherspoon, Pathways to

the Pulp, 8th ed. 2002

Considerations

Prognosis

Success rate of endodontic treatment of teeth with

vital and nonvital pulps. A meta-analysis

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

Tissue Injury and Inflammation

from:

Prognosis
Periapical

Response
Post-treatment Symptoms
Systemic Impact

Instruments
Irrigants
Medicaments
Obturating

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

Stepback
Crown-down

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

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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Extrusion of Debris

Tissue Reaction to Obturation

Short

of the apex little

response
Beyond the apex
Inflammation
Delayed healing

Ricucci & Langeland, IEJ, 1998

Guttmann & Witherspoon, 2002

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

Reddy S & Hicks L. JOE, 1998

Considerations

Post-Canal Preparation Symptoms

Prognosis

Periapical

Response
Post-treatment Symptoms
Systemic Impact

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

Considerations

48% reported symptoms after

obturation
10% or less significant symptoms
Overfill (no lesion) more pain

Prognosis

Periradicular

Response
Post-treatment Symptoms
Systemic Impact

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

Bacterial Extension
Pulp Necrosis
Apical Foramen

Short
Close
Beyond

Overinstrumentation and
Bacteremia

Periradicular Contamination

Bender et al, Oral Surg, 60

Baumgartner et al, JOE, 76

Impact

Gutierrez et al., 1999

Intracanal Bacteria in Blood

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

Conclusions (continued)

In Conclusion

Apical canal anatomy and histology are

variable and indeterminable, clinically
Instruments, materials and chemicals
should be confined to the canal

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

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Periapical Tissue Injury and

Inflammation Occurs from:
Instruments

Termination of Preparation and

Obturation

Vital pulp: 1-3 mm short

Necrotic pulp: 0-2 mm short

Irrigants
Medicaments
Obturating

Materials

Termination of Preparation and

Obturation

Bacterial Extrusion Beyond the

Apex Will Produce:

Short

of the radiographic apex

Short

of the apical foramen

Periapical inflammation

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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