Sunteți pe pagina 1din 33

PERIAPEX AND ITS SIGNIFICANCE

Seminar by
Postgraduate Student

DEPARTMENT OF CONSERVATIVE DENTISTRY &


ENDODONTICS
CHENNAI
CONTENTS

INTRODUCTION 1

DEVELOPMENT OF ROOT 2

ROOT LENGTH AND APICAL CLOSURE 4

APICAL FORAMEN ANATOMY 5

LATERAL CANALS 8

ACCESSORY CANALS 10

APICAL PULP TISSUE 12

APICAL DENTIN 14

REASON FOR ROOT CURVATURE 15

ROOT RESORPTION 15

CHANGE OF ANATOMY OF ROOT APEX 16

AGE CHANGES AT APEX 17

RADIOGRAPHIC ASSESMENT OF APICAL THIRD 18

PREPARATION OF APICAL THIRD 21

APEXIFICATION 26

DENTIN CHIP APICAL FILLING 28

PERIAPICAL SURGERY AND APEX 30

RECENT ADAVANCES 34

CONCLUSION 36
INTRODUCTION

Achievement of a perfect seal at the apex using an inert filling


material is the ultimate goal for every endodontist. The crux of
endodontics revolves around the efficient and effective manipulation and
obturation of the apical third of the root canal. The importance of a
thorough cleaning and hermetic filling of the apical part of the canal for
successful healing of the periapex was highlighted analogically as early
as 1939 itself, by Kronfeld. He has equated the microorganisms in the
root canal to an army in the “mountains” which enters the ‘plains’
through the foramina or ‘the mountain pass’. As the bacteria enters in
small numbers, they are destroyed by the ‘army’ of leucocytes is
maintained at the ‘front’ to counter the attack. A thorough cleaning and
filling would make the maintenance of the army unnecessary allowing the
environment to return to normality.

Variations in external morphological features of crowns of teeth


occur with variations in shape and size of head. External morphological
features vary from person to person. In the same way internal
morphology of crown and root also varies. Among these, the anatomy of
the root apex, its morphological variations and treatment are technical
challenges for the endodontist.

Much of the knowledge of root apex is based on exhaustive work


of Hess who studied 3000 permanent teeth and showed minute details
like extensions, ramifications, branching as well as size, shape and
number of root canals in different teeth.
Fracture of the apical third, resorption, weeping canals, immature
foramina are some of the areas which continue to be under constant
research.

DEVELOPMENT OF ROOT

On completion of formation of crown, i.e. once the enamel and


dentin has been formed till the cementoenamel junction, the inner and the
outer enamel epithelium proliferates downwards to form Hertwig’s
epithelial root sheath. This root sheath determines the size and shape of
the root of the tooth.

Root sheath takes a bend horizontally towards the dental papilla to


form epithelial diaphragm. This process partially encloses the dental
papilla and delineates the apical foramen. Soon the ectomesenchymal
cells of dental papilla present above the epithelial diaphragm starts
proliferating and root dentin deposition takes place. According to Orban,
the epithelial diaphragm i.e. future root apex will remain in place while
the tooth crown and supporting structures move occlusally. Once the
dentin is deposited to the entire length of the root, the HERS split to get
the cells of the dental sac in contact with the dentin. These cells of the
dental sac get differentiated into cementoblasts and starts laying down
cementum on radicular dentin.

Two kinds of cementum are laid down on the root. If the


cementoblasts retracts as cementum is laid down, it will be acellular
cementum. If cementoblasts do not retract and get surrounded by new
cementum the tissue formed will be cellular cementum and the trapped
cementoblasts will be called cementocytes.

Acellular cementum will be formed around the coronal and middle


third of root where as cellular cementum will be formed in the apical
third of the root with alternating layers of acellular cementum. This
incremental deposition of the cementum continues throughout the life of
the tooth and makes the layer of cementum on the apical third of the root
thicker than cervical third. This continued deposition of the cementum on
apical third maintains the length of the tooth constricts the apical foramen
and also deviates the apical foramen from the center of the apex.

The island of HERS which are left behind migrates towards the
dental sac. They remain in the periodontal ligament close to the
cementum. These cells are called cell rests of mallasez. They have the
potential to differentiate into any cell as the need arises, when they are
stimulated.
ROOT LENGTH AND APICAL CLOSURE

We should have knowledge about the dates of tooth eruption, the


completion of the root length and apical closure. Because the complex
root formation and apical closure plays an important role in the repair of
inflammed dental pulps following endodontic therapy.

Moorrees et al. (1963) studied the rot lengths and apical closure
completion dates by using images on lateral jaw radiographs. They found
that root length completion and apical closure dates by using images on
lateral jaw radiographs. They found that root length completion and
apical closure occurs early in females when compared to males.

The maxillary teeth were not studied because their images could
not be identified clearly on lateral jaw radiographs. But judging from the
data of maxillary incisors and mandibular teeth, they surmise that the
dates fro completion of root lengths and apical closures for maxillary
posterior teeth are slightly later than mandibular teeth.

Clinical significance
A funnel shaped opening exists at apex of young tooth that has
incompletely formed root. This incompletely formed root apex contains
connective tissue, blood vessels, nerves which enters and exit the root
canals. Therefore successful repair of inflammed dental pulps occurs in
teeth within complete apical closure when compared with the teeth with
completed apical closure. This may be possibly due to the unobstructed
metabolism.
The pulp capping and pulpotomy procedures are wide successful in
teeth with open apices and complete endodontic therapy has better

Tooth Emergence Co mplet ion of root Apical closure (in years)


into oral cavity length (in years)
Male Female Male female
Uppper 1st 7-8 10 ¾ 10 - -
incisor
Upper 2nd 8-9 12 11 ¼ - -
incisor
Lower 1st 6-7 8¾ 8½ 10 9½
incisor
Lower 2nd 7-8 10 9½ 11 ½ 10 ½
incisor
Lower canine 9-10 12 ½ 11 18 14
Lower 1st 10-12 13 12 16 ½ 15
premo lar
Lower 2nd 11-12 14 13 17 ½ 16 ¾
premo lar
Lower 1st 6-7 Mesial root 7 7 10 ½ 9¾
mo lar Distal root 7 ½ 7½ 10 ¾ 11
Lower 2nd 11-13 14 13 16 13
mo lar 14 ½ 13 ¾ 18 17 ¾
Lower 3rd 17-21 20 20 ¾ 23 ½ 24 ½
mo lar 20 ½ 21 24 ½ 25 ¼

prognosis in teeth with complete root end formation. In young teeth with
incomplete root end formation, partial pulpitis can be treated by pulp
capping or pulpotomy procedures thereby permitting normal root end
development i.e. apexogenesis. But in teeth with severely inflammed or
necrotic pulps, the tissues must be removed and the root canals must be
debrided and cleansed. Ca(OH)2 is placed in root canals and completion
of root canal therapy should be delayed until the root end formations has
been completed. This process is known as apexification.

APICAL FORAMEN
Structure:
In young incompletely developed teeth the apical foramen is funnel
shaped with wider portion extending outward. This mouth of the funnel is
filled with fibrous tissue which later will be replaced by dentin and
cementum. As the root apex becomes lined with cementum which
extends to a short distance into the root canal. This is the cementodentinal
junction. CDJ is not present at the extreme end of the root but a few mm
within the main root canal. The apical foramen is not the most constricted
portion of the root canal.

Kuttler in 1955, perfomed studies on microscopic structure of root


apexes. He says that the narrowest diameter of the canal is definitely not
at the site of exiting of the canal from the tooth but usually occurs within
the dentin just prior to the initial layers of cementum. He refers this
position as the “minor diameter”. Some calls it “apical constriction” and
some as “histologic foramen”.

The diameter of the canal at the site of exiting from the tooth is
called “major diameter”. Major diameter was found approximately twice
as wide as minor diameter. In young patients (18-25 years) the distance
between minor and major diameter is approximately 0.5mm and in the
older patients (55 years and above), the distance between minor and
major diameter is approximately 0.67mm.

Clinical significance

Kuttler says that the canal preparations and obturations should be


terminated at the minor diameter. Major advantage is that during
obliteration procedures minor diameter provides a bottle neck area. This
allows the rapid development of a solid apical dentin matrix. This will
enhance the possibility of retaining the filling materials and sealers within
the canal. Pain free treatment can be done because of less or no
impingement on periapical tissues. However techniques to locate exactly
the minor diameter are lacking.

Location:

The apical foramen is not always located at the centre of the apex
of the root. According to Ingle, it is uncommon to find the foramen
exiting at the centre of the apex. It may exit on the mesial, distal, buccal,
lingual portions of the root.

Anatomic studies have shown that the apical foramen coinciding


with the apex is seen only in 17-34% of cases. On an average, it is located
0.4 to 0.7 mm away form the anatomic apex. In few cases the apical
foramen was found 2-3 mm away from the apex.

Shape:

Shape of the apical foramen can be round , oval. It may sometimes


have unusal shapes such as hourglass shape, semilunar or serrated.
Clinical significance of apical foramen:

 The apical constriction acts as a natural stop for the filling

materials.
 Size and shape of the apical foramen should always be maintained.
It should be neither enlarged nor blocked
 Care should be taken to prevent over instrumentation or extrusion

of the root canal filling materials beyond the apex.

LATERAL CANALS AND ACCESSORY CANALS

According to the glossary of American Association of


Endodontists, lateral and accessory canals are differentiated as

Lateral canal: Is a canal that is located at approximately at right angles


to main root canal

Accessory canal: is the one that branches off from main root canal,
usually in the apical region of the root.

Accessory foramina: are the openings of the accessory and lateral canals
on the root surface.

Development:
 They may form when the epithelial root sheath disintegrates before
the dentin is elaborated
 They may also result firm lack of dentin elaboration around a blood

vessel which is present in the periradicular connective tissue.

Lateral and accessory canals are present in greater numbers in teeth


of younger individuals. As the tooth ages, some accessory canals may
become obliterated by further dentin or cementum formation. They
contain fibrous tissue. Fibroblasts, collagen fibers, nerves, capillaries
and some macrophages may be present within them. The connective
tissue is the same as that found in pulp but more closely resembles the
connective tissue of the periodontal ligament. Usually blood vessels
enter the tooth, some through the apical foramen, some through the
lateral aspects of the root through the accessory foramina.

According to green, the incidence of accessory canals ranged from


10% in maxillary central incisors and mandibular canines to 47% in
mandibular 2nd premolars with the other teeth having incidences
within this range.

Lateral canals: lateral canals are found more in roots of posterior teeth
and occasionally in roots of anterior teeth. More common in bifurcation
and trifurcations regions of molar teeth. Hess in 1925, by the use of
vulcanite corrosion specimens detected, the incidence of 16.9% of lateral
canals in all teeth.

Kramer in 1960 demonstrated large blood vessels in the lateral


canals in furcation regions using vascular injection technique. In some
instances the lateral canals in furcation region are seen traverse the root in
the apical direction and finally entering the root canal in the middle or
apical third.

Accessory canals:

In anterior teeth, Seltzer 1966, observed 34% incidence of


accessory canals. Accessory canals are seen frequently in apical third
of roots. According to Hess (1983) accessory foramina have a mean
diameter of 6 to 60 µm. In many teeth, the width of the accessory
canals and sometimes lateral canals is exceedingly small, permitting
only presence of small caliber blood vessels and their supporting
stroma. Usually these small canals cannot be observed on radiographs.

Apical delta:

The presence of multiple accessory and lateral canals is a rule


rather than an exception which raises the question regarding the fate of
pulp tissue in those canals following endodontic therapy.
The accessory and lateral canals arhe avenues for the interchange
of metabolic and breakdown products between the pulp and the
periodontal tissues. Exposure of lateral canals to the environment due
to the presence of deep periodontal pockets may lead to inflammation
or necrosis of pulp. Conversely breakdown products of inflammatory
pulp lesions may have effect on periodontal tissues via these ccanals.

Following endodontic therapy, in vital teeth, the lateral and


accessory canals tend to become obliterated by deposition of
cementum with passage of time. In teeth with totally inflammed or
necrotic pulps, granulation tissue is found in accessory canals prior to
endodontic therapy. Following endodontic therapy, inflammatory
tissue will get resorbed and replaced with uninflammed connective
tissue.

When pulp is extirpated from the main canals, a clot forms at the
site of the wound. Repair of the wound subsequently occurs if
accessory blood supply is present. In case of “Y” shaped branching of
the pulp i.e. apical delta, following endodontic treatment, the pulp
tissue in uninstrumented branches may become inflammed but usually
retains its vitality with passage of time, continous deposition of dentin
or cemntum tends to narrow the lumina of these canals.
Lateral and accessory canals are difficult to clean adequately.
Thorough and effective irrigation techniques should be carried out. A
tooth with multiple accessory canals in the apical third may harbour
microorganisms and debris which may continue to irritate the periapex
and cause pain inspite of proper filling of the principal canal.
Peripaical surgery is indicated in such cases.
Apical pulp tissue:

The apical pulp tissue is mainly found in the apical end of the root
canal. Most probably continuing into the surrounding periapical region.
The apical pulp tissue differs structurally from the coronal pulp tissue.
The coronal pulp tissue contains mainly of cellular connective tissue and
fewer collagen fibers, whereas the apical tissue is more fibrous and
contains fewer cells.

Histochemical studies by Yamashi et al. in 1986, demonstrated


large concentrations of glycogen in the apical pulp tissue, a condition
compatible with the presence of anaerobic environment. The fibrous
tissue in apical root canal is similar to that of periodontal ligament. In
gross appearance, the collagenous apical tissue is whitish in colour. This
fibrous tissue acts as a barrier against apical progression of pulpal
inflammation. In partial or total pulpitis, however complete inhibition of
inflammation does not occur.

Inflammatory exudates may be found in the periapical tissues, even


thorugh the apical tissue may be free of such exudates.
Blood and nerve supply:

The fibrous structure of apical pulp tissue supports the blood


vessels and nerves which enter the pulp. The pulp of the tooth is supplied
by number of blood vessels which originate in the medullary space of
bone surrounding the root apex. These blood vessels course through the
PDL before entering into the apical foramen as arterioles. The width of
these vessels may be same a s capillaries as they lack the elements in the
walls. The blood vessels ramify in the apical pulp tissue. Projection
microangiographs shows that, on entering the apical foramen the apical
artery divides almost into several principle or central arteries. The blood
vessels are surrounded by large myelinated nervous sheath also branch
after they enter the pulp. Scanning electron microscope studies have
shown the presence of small helmet like structures in the region of apical
foramen. They are thought to protect blood vessels and nerves from
damage due to the masticatory stresses or from minor trauma.

Nerve supplies of the pulp and periodontal ligament provides


background for the interrelationship of pulp and periodontal disease. An
inflammatory and degenerative process involving the PDL could affect its
blood supply and that of some portions of the pulp. Conversely a disease
process affecting the pulpal blood vessels would probably influence some
of the blood vessels of the PDL. Since nerve supply is laso closely
related, periodontal inflammation can cause pain similar tooth ache
caused by pulpitis.
Clinical significance in endodontic therapy:

The clinical significance is especially in giving endodontic therapy


for teeth with vital pulps. When vital pulp tissue is removed from the root
canal tissue especially with a barbed broach the severance of pulp tissue
from PDL is not under control of operator. The severance can occur
anywhere in the root canal or even beyond the apical foramen, however
in the periodontal ligament, when the later type occurs, ensuing
hemorrhage cause painful pericementitis.

Apical dentin:

In the apical region, odontoblats of the pulp are absent or flattened


or cuboidal in shape. The dentin that is not as tubular as coronal dentin,
but instead more amorphous and irregular. This type of dentin is called
sclerotic dentin. The amount of sclerotic dentin generally increases with
age. At the orifices of root canals of younger teeth, the dentinal tunules
become more oblique. In older teeth, the floor of the pulp chamber is
irregular and atubular with the presence of atubluar calcospheres.

Studies by Coughlam in 1985, have revelaed under gorund


sections that thie dentin has two zones;
a) Peripheral translucent zone
b) Inner opaque zone

Opaque zones are more closely packed and wider than those of
translucent zone. Couhlam concluded that transparency of apical dentin
was due to diminution in width of tubules.
The use of isotope studies by Hampson in 1964 have shown that
apical dentin is more sclerotic than coronal dentin. The sclerotic apical
dentin is considerably less peircable than the coronal dentin. This reduced
permeability has significance because the sclerosed dentinal tubules are
less readily penetrated or are impenetrable by microorganisms or other
irritants.

Reason for root curvature in the apical third:

When the tooth erupts into the oral cavity and becomes functional,
its root formation is not completed. It is wide open and the Hertwig’s
epithelial root sheath, a circular curtain like structure, is active with its
root formative function.

Two important things may happen as this tooth becomes functional

 It is made to bear the biting stress which may move the tooth in
mesial direction and
 The occlusal load may disturb the curtain like Hertwig’s epithelial
root sheath at the apical third.

Break in the continuity of the circular curtain like structure of the


root sheath, due to stress transmitted by the biting forces, may be the
reason for the abundant occurrence of accessory canals in the apical third.
Root resorption:

Shallow resorption of dentin in the apical portion of the root canal


are normal occurrences. Resorption of cementum and dentin occurs on
the body of the root also at the periapical region. Apical root resorption is
mainly due to

a) Orthodontic tooth movement


b) Inflammation of apical pulp and peripaical periodontal
tissues
Orthodontically induced root resorption is mediated by
prostaglandins elaborated by localized cells which stimulate osteoblastic
activity. The resorption widen the apical foramen leaving a funnel shaped
structure. As inflammation subsides repair of resorbed region occurs by
deposition of secondary cementum.

Change in the anatomy of root apex:

As a result of resorption and repair change in the anatomy of the


root apex occurs with passage of time. During orthodontic tooth
movement, the anterior component of force causes the teeth to move
mesially. The teeth also have a continuous eruptive force. These
combined forces occlusally and mesially cause tension on the distal side
causing bone apposition and pressure on mesial side causing resorption.
Thus while the principal apical foramen which is in the centre of the root
s originally will gradually shift towards one side sometimes occlusally.
Age changes at the periapex:

-Denticles and dystrophic mineralisations


-Secondary dentin and cementum deposition

Dystrophic mineralisations:

Brynolf found diffuse, scattered dystrophic mineralisations in


approximately 7% of human upper incisors. These mineralisations are
located within and around the collagen fibres and rarely in the myelin
sheaths of the nerves in the apical pulp tissue. The mineralisations may
vary in appearance from fine, diffuse fibrillar variety to large denticle like
accumulation.

Denticles/pulp stones:

Denticles are formed around foci of mineralizing pulp tissue


components such as collagen and nerve fibers, blood vessels, ground
substance, inflammed and necrotic cells. Denticles are composed of
tubular dentin and atubular mineralized material and can be attached or
embedded being partially or completely surrounded by dentin. In the
apical third of the root approximately 15% of teeth show pulp stone and
more than one pulp stone is usually found.

Clinical significance:

Denticles found within the pulp tissue in the apical third of the root
may account for some difficulties in root canal instrumentation. During
reaming or filing of root canal they may become detached and impacted
into the apical foramen rendering further instrumentation difficult.

Secondary dentin and cementum deposition:

Secondary dentin is deposited contiuously by the radicluar pulp


tissue. Secondary dentin is seen on the root canal walls of some teeth and
in greater quantities in periodontlally involved teeth. Towards the apex of
the tooth, the dentinal tubules appear to blend with cementum canaliculi.

Clinical significance:
The apical foramen or foramina tend to become obliterate by both
the deposition of secondary dentin within the root canal and by the
deposition of cementum outside the root canal. Continuous dentin and
cementum deposition will reduce the size of apical foramen but complete
closure does not occur as long as vital pulp tissue remain.

Radiographic assessment of apical third:

The lateral canals, accessory canals and other anantomic


aberrations cannot be easily identified. The clinician shouls have sound
knowledge about these anatomic variations. Clinically also we shouls
examine carefully for extracanals by probing the potential area using a
sharp pointer or an endodontic explorer. Radiographically, we can assess
and sometimes identify the anatomic variations.
When the radiograph shows root canal that descends from the
puplpal floor and suddenly stops in the apical reion then, bifurcation or
trifurcation in the apical region can be expected. To conform this, a
second radiograph is exposed from a mesial or distal angulation of 10-
30º. This resultant film will show more roots or vertical lines indicating
peripheries of additional root surfaces.

If the root canal shadow abruptly stops in the middle third of the
root or if the diameter of the root canal suddenly narrows down then it
denotes that the root canal may be dividing into two. This is very
common occurrence in mandibular premolars. If there is a lateral
radiolucency present in the apical one third of the root, it may indicate the
possibility of lateral canal accessory canals or presence of periodontal
lesions.

If there is a radiolucent line running along the diagnostic


instrument whose long axis is not in relation to the instrument then there
is high chance of additional canal. The recent advancements like
xeroraiography, radiovisiography, digital substraction radiography,
computed tomography also will be helpful for identifying these minute
anatomical variations.

Other features of apex on radiographs:

i) Thin “pinched” apex – care should be taken during


instrumentation to avoid perforation.
ii) Bulbousapex – Bulbous appearance of apex is due to
hypercementosis. In cases of bulbous apex apical constriction
may be significantly shorter from the radiographic apex
compared to normal teeth.

iii) Resorbed apex – Advanced inflammation at the periapex


usually causes resorption of cementum, either widening of
apical foramen. Such changes will make working length
determination difficult with proper apical preparation and
condensation of gutta-percha. So apical stop should be created
in such teeth.

iv) Blunderbuss apex – a newly formed tooth would normally


show an incompletely forced root having a wide root canal and
an open apex. Such a canal is termed immature or blunderbuss
canal.
Apical Preparation:

Length determination:

The first step in the prepration is the location of the foramen in the
root apex. Although a radiographic assessment with a measured endo
instrument in the canal is an accepted procedure for the determination of
the tooth length, measurements using electronic instruments are
becoming increasingly popular. Electronic measurement of the tooth
length according Grossman (1981), is an effective method in 80 to 90%
of the cases compared to the radiographic method. Neosono D, according
to some clinicans, indicates the exact location of the foramen with
reasonable accuracy. Galland (1985) recommends electronic apex finder
for those who perform endo treatment infrequently.

Determination of the working length is an essential step in


obtaining the hermetic seal as wrong estimation could either lead to an
enlarged foramen resulting in i) periapical irritation, ii) possible weeping
of the canal, and iii) Loss of control during obturation, or lead to
apreparation short of foramen with the resultant ledge formation and
accumulation of dentin mud.

Instruments & instrumentation:

Time spent on the proper preparation of the apical portion greatly


simplifies the subsequent canal preparation. Two general principles to be
adhered to, while preparing the apical third, are
 The maintenance of the spatial integrity of the foramen
 Smooth shaping of the original course of the canal
Careful selection of instruments and special manipulative
techniques are essential requirements for a successful preparation of
apical zone. Improperly prepared access cavity would presupposedly
affect the preparation of the apical zone. Impingement of the endo
instrument coronally would result in either ripping of the foramen or
formation of a ledge and thus making it almost impossible to obtain a
satisfactory seal.

Ninety percent of the canals are curved (Christie & Peikoff


1980), and precurving of the files is a must in all such cases. By
precurving the instruments the original course of the canal and location
of the foramen are preserved.

Slight deviation from proper handling of the files could


disastrously spoil the preparation. Files are not to be given quarter turn
bites into dentin or pulled forcibly with lateral pressure along the canal
walls when preparing the apical end of the canal. Rotation of
instruments has been found to violate the basic principle as it forms an
‘hour glass’ outline rather than a smooth taper near the apex (Weine et
al. 1975).

Flexible files are preferred over stiffer varieties since they may
change the course of the canal, form a ledge or transport the foramen by
ripping. D- type files (produced from rhombus blanks) are more flexible
than regular K- type files (produced from square blanks) in size no: 30
and above (Anderson et al. 1985). The new K- type file (triangular cross
sections ) is more flexible than H- file (Roane et al 1985).
Methods of preparation:

Preparation design has an influence upon the final seal. Step back
or flaring type of preparation of the apex is found to be advantageous
over the conventional method (Allison et al. 1979). Flared preparation
provides a cleaner environment, better receptacle for the obturating
material, and a stronger apical dentin matrix (Weine 1982). Chances of
apical ripping and shifting I foramen are less with step- back technique
(Christie & Peikoff 1980).

Various special techniques have been introduced by different clinicians


for acceptable preparation of a curved apical third (Mullaney 1979;
Weine 1982; Roane et al. 1985). Roane et al. (1985) introduced a new
‘balanced force concept’ using the latest K- type file, triangular cross cut,
for the preparation of apical zone in deeply curved canals.

The traditional approach to canal prepration was to negotiate and


prepare the apical one third of the root canal first followed by a coronal
flaring technique to facilitate obturation. In this technique the clinician
selects a small diagnostic file, places an appropriate curve on the
instrument, then eagerly works the file to length. When a file cannot be
carried to the terminus, it is removed and the root canal space is
reirrigated. The file is then recurved and reinserted, and a more focused
effort is made to move it to length. The break down is the failure to
recognize that frequently the rate of taper of the instrument exceeds the
rate of taper of the canal that prevents the file’s apical movement. When
an instrument binds on its more shank side cutting blades, the clinican
loses apical file control.
Attempting to negotiate and prepare the apical one third of the
canal first is challenging in the most delicate part of the microanatomy.
Often a straight root holds a curved canal. Clinician need to recognize
that most canals move through multiple planes of curvature over length.
Mesial and distal curvatures are best visualized radiographically.
However, buccal and lingual curvatures also need to be appreciated.
Additionally, canals typically exhibit their greatest curvatures and deep
divisions in their apical extents. The degree, length and abruptness of a
canal curvature, in conjunction with its propensity to divide, should be
factored into the preparation sequence. Specifically passing a precurved
negotiating file through a coronally tight and under prepared canal
straightens the instrument. Unknowingly attempting to work straighter
files to length in curved canals first invites the block, then predisposes the
patient to the formation of a ledge. Further contributing to breakdowns in
the apical preparations first, sequence is the fact that nonflared canals
hold a minimal volume of irrigating solution that inturn, invites the
accumulation of dentin mud. Working short, in conjunction with
attempting to prepare the apical one third first, has led to canals that have
been ledged, externally transported, or apically perforated.

Irrigation:

A strict rule to follow is to irrigate the canal copiously between


each instrumentation. It facilitates the removal of dentin shavings and
maintains the cutting efficiency of the instruments by relieving clogging.
Once the dentin mud settles at the apical level, it becomes difficult to be
dislodged.
Since 1955, Grossman (1982) has advocated the alternate use of
5% NaOCl with 3% hydrogen peroxide. The effervescence obtained on
using hydrogen peroxide, he advocated would bring the shavings to
surface. However, in a study conducted by Svec and Harrison (1981), the
difference in the accumulation of dentin mud after the use of NaOCl
alone and with 3% hydrogen peroxide is found to be statistically
insignificant. Furthermore, effervescence due to the use of 3% hydrogen
peroxide always bubbles upwards. Hence, the use of the same in the
upper teeth would detrimentally drive the mud apical wards instead of
crown wards (Schilder & Yee 1984). The circulation of the irrigant has
been found to remain short of the apical third of the canal, particularly in
curved teeth, unless specially made fine needles are used (Goldman et al
1976).

Chlorhexidine has been advocated for endodontic use due to its


broad spectrum antimicrobial activity and least irritant nature on the
periapical tissues. However, its inability to dissolve tissue fragments has
been a problem. Though NaOCl is considered as the irrigant of choice,
chlorhexidine gluoconate should be considered in conditions such as
young permanent teeth with immature apices or open apices.

Obturation:

Sealing is done to eliminate all the portals of entry from the root
canal into the adjacent periodontal tissues through which exudates,
bacteria or their toxins might pass; and to make the environment
favourable for healing. Ingle (1956) determined 63% of the root canal
failures to be due to inadequate filling. Accessory foramina if left open
and remain unfilled can lead to failure of treatment. The necessity to
provide hermetic sealing of the apical foramen as well as filling of the
accessory canals has brought forth many dynamic changes in the
obturation techniques.

Ideal response after endodontic treatment is the biologic closure of


the apex. Many methods were tried. Nysgaard Ostby (1961) attempted
natural healing at the apex by inducing bleeding. The subsequent
formation of the clot was hoped to serve as a matrix for tissue ingrowth.
However, the formation of biological closure was found negated as the
clot fibrin was observed to degenerate within the canal coronally.
Consistently successful results have been reported in teeth which had
treatment (Holland & Souza 1984). The pulp at the apex has been adviced
(Leonardo et al 1984) not to be disturbed either by way of
instrumentation or medicaments; extreme care and respect to be shown to
the vitality of the pulp.

Apexification:

In young teeth with incomplete root end formation, partial


pulpitides can be treated by pulp capping or pulpotomy procedures,
thereby permitting normal root end development (apexogenesis). In teeth
with severely inflammed or necrotic pulps, the tissues must be removed
and the root canals must be debrided and cleansed in the usual manner.
Thereafter, completion of endodontic therapy should be delayed until root
end formation has been completed. Such a procedure has come to be
known as apexification. In comparing the results of treatment in 166
traumatized incisors, Kerkes et al (1980) found that, in 9 to 12 year old
patients, apexification procedures produced better results than standard
root canal treatments with filled root canals. In 18 year old patients,
standardized root canal therapy yielded the best results.

Various procedures and medicaments have been recommended for


inducing apexification. These have induced Tricresol and formalin
(Cooke and Rowbotham, 1960); antibiotic pastes (Ball, 1964); Tricalcium
phosphate (Koenigs et al, 1975) and calcium hydroxide.

Based on the results of numerous investigations, calcium hydroxide


has emerged as the drug of choice for apexification. Both the alkalinity
and the calcium ion are apparently needed to induce hard tissue formation
(Tronstad et al 1981). Other calcium compounds, such as calcium
chloride, have not been effective nor have other hydroxides, at the same
pH, such as ammonium or barium hydroxide.

Numerous recommendations have been made for vehicles to be


used for the Ca(OH)2. These include camphorated p-chlorophenol,
iodoform, water local anesthetic solution, glycerol and other
medicaments.

For increasing radio opacity, additions of barium sulfate (Stewart


1975), solutions of 10% iodine and 20% potassium iodide or diatrizoate,
a form of organic iodine, have been recommended. According to Smith
and Woods (1983), the diatrizoate compounds are more and absorbable
than barium sulfate.

Histologic studies indicate that various types of hard tissue that


resembles bone or cementum or dentin or osteodentin are induced at the
apex. Satisfactory results have been reported from standard endodontic
therapy and root canal filling considerably short of the developing root
apex. Under such circumstances, if Hertwig’s root sheath has not been
damaged, there is a reasonable probability that the apex will develop in a
normal manner.

Dentin chip apical filling:

A method finding increasing favour, is the apical dentin chip plug


against which other materials are then compacted. Dentin chip plug
provides a “biologic seal” rather than a mechanochemical seal. Gottlieb
and Orban noted cementum forming around dentin chips in the PDL as
early as 1921. El Deeb stated that apical dentin plug is significantly
effective in confining the irrigating solutions and filling materials to the
canal space. Oswald and Friedman concluded that dentin chips lead to
quicker healing, minimal inflammation, and apical cementum deposition,
even when the apex is perforated.

Method of use:

The dentin chip technique has been used and taught at the
universities of Oregon and Washington. After the canal is totally debrided
and shaped and the dentin no longer “contaminated”, a Gates Glidden
drill or Hedstroem file is used to produce dentin powder in the central
position of the canal. These dentin chips may then be pushed apically
with the butt end and then the blunted tip of a paper point. They are
finally packed into place at the apex using a premeasured file one size
larger than the last apical enlarging instrument. 1-2mm of chips should
block the foramen.
The Japanese found they could totally prevent apical microleakage
if they injected 0.02ml of clearfil bond dentin adhesive into the coronal
half of the dentinal apical plug. Completeness of density is tested by
resistance to perforation by a no. 15 or 20 file. The final gutta-percha
obturation is then compacted against the plug.

Efficacy of dentin chip apical obturation:

One of the positive effects of a dentin plug filling is the elimination


of extrusion of sealer or gutta-percha through the apex. This reduces
periradicular inflammation. In a monkey study done at Loma Linda
indicated that the inorganic component of dentin, Hydroxyapatite is the
principal stimulant in proceeding more hard tissue formation and less
inflammation than fresh dentin chips.
The dentin chip apical plug is a valuable contribution to endodontic
success and deserves to be more widely employed.
Conclusion:

The morphological variations and the technical challenges involved


in treatment of the apical third seems infinite. It has to be remembered
while treating the apical third that the proximity of the apices of certain
teeth are in close association with important structures like maxillary
sinus an inferior alveolar nerve. Inadequate attention and improper
handling of the apical third of these teeth may lead to serious clinical
implications.

The root apex is morphologically the most complex region


therapeutically a challenging zone and prognostically an important and
unfortunately most obscure and unclear area. So, endodontist should have
detailed knowledge of the anatomic variations and mechanical challenges
involved in the treatment of apical third for effective and efficient
management during endodontic therapy.