Root Canal Obturation:

Determining The Optimal Obturation Length

Dr.\ Ranya Elemam

BDS. Msc Endodontics Email : Ranya_Elemam@yahoo.co.uk

9/11/2013

Aim
Provide an understanding in determining termination
of obturation.

Ranya Elemam

Root Canal Obturation

9/12/2013

Objectives
Understand The Anatomical Land Marks Of Apical Zone Of The Root . Know What Literatures State About The Termination Length Of The Obturation . Recognize The Relation Between The Obturation Length And Endodontics Outcome.

Ranya Elemam

Root Canal Obturation

9/12/2013

Where to End the Gutta Percha?

Ranya Elemam

Root Canal Obturation

9/12/2013

Recommendation by Literatures: 1
Termination should be to the apical constriction (Kulter et al 1955)

Kuttler Y. Microscopic investigation of root apexes. Journal of the American Dental Association (1939). 1955;50(5):544-52.
Ranya Elemam Root Canal Obturation 9/12/2013

Recommendation by Literatures: 2
Obturating short of the radiographic apex 0.52.0 mm (Weine 1996 )

FS W. Endodontic therapy. 6th ed. ed: MO: Mosby; 1996.

Ranya Elemam Root Canal Obturation 9/12/2013

Recommendation by Literatures: 3
In presence of root and/or bone resorption should be to even shorter length. ( Walton And Torabinejad 2002 )

Richard E. Walton MT. Principles and practice of endodontics. 3rd ed ed: Philadelphia, Pa. ; London : Saunders, c2002; 2002
Ranya Elemam Root Canal Obturation 9/12/2013

Recommendation by Literatures: 4
Apex is a more reliable reference point. (Ricucci 2003)

5. Ricucci D, Bergenholtz G: Bacterial status in root-filled teeth exposed to the oral environment by loss of restoration and fracture or cariesa histobacteriological study of treated cases. Int Endod J 36:787, 2003.
Ranya Elemam Root Canal Obturation 9/12/2013

Recommendation by Literatures: 5
Debridement and obturation to the radiographic apex, results in material being extruded into periradicular tissues. (Schilder 1974)

Schilder H. Filling root canals in three dimensions. Dental clinics of North America. 1967:723-44.

Ranya Elemam

Root Canal Obturation

9/12/2013

Ranya Elemam

Root Canal Obturation

9/12/2013

Anatomical Rational

Apical Anatomy

Ranya Elemam

Root Canal Obturation

9/12/2013

Apical Anatomy

Anatomical Apex

Radiographical apex
Ranya Elemam Root Canal Obturation 9/12/2013

Anatomical Landmarks

1. Apical Construction AC (Minor Apical Diameter) 2. Cement dentinal Junction CDJ

3. Radiographic apex

Ranya Elemam

Root Canal Obturation

9/12/2013

AC: Apical Construction

May be more conceptual than real

Considered the part of the root canal with the smallest diameter.
The reference point clinicians use most often to terminate shaping, cleaning, and obturation present less than half the time, particularly when apical root resorption was a factors .

0-2.5 mm from the apex and increases with age because of cementum deposition believed to coincide with the cemento-dentinal junction (CDJ)
1. Buckley M, Spangberg LS: The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79:92, 1995. 2. Castelli WA, Caffesse RG, Pameijer CH, Diaz-Perez R, Farquhar J: Periodontium response to a root canal condensing device (Endotec). Oral Surg Oral Med Oral Pathol 71:333, 1991. 3. Levitan ME, Himel VT, Luckey JB: The effect of insertion rates on fill length and adaptation of a thermoplasticized gutta-percha technique. J Endod 29:505, 2003. 1. Kuttler Y: Microscopic investigation of root apexes. J Am Dent Assoc 50:544, 1955.

Ranya Elemam

Root Canal Obturation

9/12/2013

Cement dentinal Junction (CDJ)

The point in the canal where cementum meets dentin and where pulp tissue ends and periodontal tissues begin. The location of the CDJ in the root canal varies considerably. Estimate placed approximately 1 mm from the AF. Based on histological section and ground specimen and cant located precisely on radiograph

Lawley GR, Schindler WG, Walker WA, III, Kolodrubetz D: Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification. J Endod 30:167, 2004. Machnick TK, Torabinejad M, Munoz CA, Shabahang S: Effect of MTAD on flexural strength and modulus of elasticity of dentin. J Endod 29:747, 2003.

Ranya Elemam

Root Canal Obturation

9/12/2013

Radiographic Apex:
It is the tip of the root where as determined radioghraphicaly location of the foramen not at the apex as deviations occurred in 92% of the roots.

Shaping to the radiographic apex is likely to produce over instrumentation with

potential clinical squeals of post treatment pain and inoculation of microorganisms into periapical spaces.
Buchanan L: Continuous wave of condensation technique. Endod Prac 1:7, 1998. El Ayouti A, Weiger R, Lst C: Frequency of overinstrumentation with an acceptable radiographic working length. J Endod 27:49, 2001.

Ranya Elemam

Root Canal Obturation

9/12/2013

Thoughts: Imperfection !

Thought is out only .5-1 mm

0.5-1 mm

http://www.endomail.com
Ranya Elemam Root Canal Obturation 9/12/2013

Reality

Cohen KMHaS. Cohen's Pathways of the Pulp 10th Edition ed: Mosby; 2011.
Ranya Elemam Root Canal Obturation 9/12/2013

Reality

Cohen KMHaS. Cohen's Pathways of the Pulp 10th Edition ed: Mosby; 2011.
Ranya Elemam Root Canal Obturation 9/12/2013

This variable structure in the apical region presents

challenges for root canal therapy !

Ranya Elemam

Root Canal Obturation

9/12/2013

Pulpal And Periapical Condition ??

Pulpal Condition

1. Vital Pulpectomy: (Irreversible Pulpitis ) : procedures terminate 2 to 3 mm short of the radiographic apex.

2. Pulpal Necrosis: procedures terminate at or within 2 mm of the radiographic apex (0 to 2 mm).

Ranya Elemam

Root Canal Obturation

9/12/2013

Periapical Condition

1 mm

1.5 mm

2 mm

Ranya Elemam

Root Canal Obturation

9/12/2013

Other Considerations
Re-treatment
It is preferable to clean the canal to the AF in retreatment !

Wu MK, Wesselink PR, Walton RE. Apical terminus location of root canal treatment procedures. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 2000;89(1):99-103.

Systemic considerations
There is no definitive evidence that introducing bacteria or antigens from infected canals into the bloodstream causes systemic diseases, it would seem prudent to avoid this situation when possible.

Debelian G, Olsen I, Tronstad L. Anaerobic bacteremia and fungemia in patients undergoing endodontic therapy: an overview. Ann Periodontol 1998;3:281-7 Wu MK, Wesselink PR, Walton RE. Apical terminus location of root canal treatment procedures. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 2000;89(1):99-103.

Obturation Length And Treatment Outcome

Ranya Elemam

Root Canal Obturation

9/12/2013

Obturation Length And Treatment Outcome

Length of root canal filling was found to influence the outcome of the endodontic treatment. The most successful outcomes were associated with teeth without apical extrusion of the filling material .The overextension of filling materials was combined with delayed healing

Elemam RF, Pretty I. Comparison of the success rate of endodontic treatment and implant treatment. ISRN dentistry. 2011;2011:640509.
Ranya Elemam Root Canal Obturation 9/12/2013

The importance of length control in obturation relates to extrusion of materials. Studies indicate that extrusion decreases the prognosis for complete regeneration.

Swartz DB, Skidmore AE, Griffin JA, Jr: Twenty years of endodontic success and failure. J Endod 9:198, 1983.

Obturation Length And Treatment Outcome

When the therapeutic procedures shorter 2 mm from or past the radiographic apex, the success rate for INFECTED CANALS was approximately 20% lower than that when the procedures terminated at 0 to 2 mm.

Ranya Elemam

Root Canal Obturation

9/12/2013

Obturation Length And Treatment Outcome

Periapical pathosis was found with 43% of the teeth with overfills.
An overfilling resulted in a failure rate of 37%. this was four times greater than cases that filled short.

Buckley M, Spangberg LS. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 1995;79(1):92-100. Swartz DB, Skidmore AE, Griffin JA, Jr. Twenty years of endodontic success and failure. Journal of endodontics. 1983;9(5):198-202.
Ranya Elemam Root Canal Obturation 9/12/2013

Obturation Length And Treatment Outcome

Teeth with root canal llings 02 mm from the root apex showed signicantly better periradicular conditions than teeth with either overllings or underllings The success rate in group of teeth obturated from 0 to 1 mm short of the apex was 28.9% better than group of teeth those obturated beyond the apex and 5.9% better than group of teeth where they were obturated 1 to 3 mm short of the apex

Moreno JO, Alves FRF, Gonalves LS, Martinez AM, Ras IN, Siqueira Jr JF. Periradicular Status and Quality of Root Canal Fillings and Coronal Restorations in an Urban Colombian Population. Journal of endodontics. 2013;39(5):600-4 Schaeffer MA, White RR, Walton RE. Determining the optimal obturation length: a meta-analysis of literature. Journal of endodontics. 2005;31(4):271-4. Ranya Elemam Root Canal Obturation 9/12/2013

Obturation Length And Treatment Outcome

On the basis of biological and clinical principles, instrumentation and obturation should not extend beyond the apical foramen.

Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2. A histological study. Int Endod J. 1998;31(6):394-409.

Ranya Elemam

Root Canal Obturation

9/12/2013

Clinical determination of apical canal morphology

is difficult at best. !!!

Ranya Elemam

Root Canal Obturation

9/12/2013

Conclusions
The apical limit of instrumentation and obturation continues to be the subject of major controversy in root canal therapy. However ,the use of an apex locator in conjunction with radiographs and sound clinical judgment makes this decision

more logical.

Cohen KMHaS. Cohen's Pathways of the Pulp 10th Edition ed: Mosby; 2011.
Ranya Elemam Root Canal Obturation 9/12/2013

Remember:

A little short is better and more conducive to a successful root canal procedure !!

Ranya Elemam

Root Canal Obturation

9/12/2013

Ranya Elemam

Root Canal Obturation

9/12/2013

Recommended Articles/books:

1. Schaeffer MA, White RR, Walton RE. Determining the optimal obturation length: a meta-analysis of literature. Journal of endodontics. 2005;31(4):271-4. 2. Wu MK, Wesselink PR, Walton RE. Apical terminus location of root canal treatment procedures. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 2000;89(1):99103. 3. Cohen KMHaS. Cohen's Pathways of the Pulp 10th Edition ed: Mosby; 2011.

Ranya Elemam

Root Canal Obturation

9/12/2013

Ranya Elemam

Root Canal Obturation

9/12/2013

Question ?