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Apical terminus location of root canal treatment procedures

Min-Kai Wu, MD, MSD, PhD, a Paul R. Wesselink, DDS, PhD, b and Richard E. Walton, DMD,
MS, c Amsterdam, The Netherlands, and Iowa City, Iowa
ACADEMIC CENTREFOR DENTISTRYAMSTERDAM (ACTA)AND UNIVERSITYOF IOWA, COLLEGE
OF DENTISTRY

The apical termination of root canal treatment is considered an important factor in treatment success. The exact
impact of termination is somewhat uncertain; most publications on outcomes are based on retrospective findings. After vital
pulpectomy, the best success rate has been reported when the procedures terminated 2 to 3 mm short of the radiographic
apex. With pulpal necrosis, bacteria and their byproducts, as well as infected dentinal debris may remain in the most apical
portion of the canal; these irritants may jeopardize apical healing. In these cases, better success was achieved when the proce-
dures terminated at or within 2 mm of the radiographic apex (O to 2 mm). When the therapeutic procedures were shorter than
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. Clinical determination of apical canal anatomy is difficult. An apical constriction is
often absent. Based on biologic and clinical principles, instrumentation and obturation should not extend beyond the apical
foramen. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:99-103)

Canal instrumentation includes both cleaning and On the other hand, the extension of the root filling should
shaping. Cleaning is the significant reduction of tissue as not be too short. If the apical canal is not completely
well as micro-organisms and their by-products from the obturated, residual bacteria may survive and multiply1;
pulp system. With a vital pulp, micro-organisms would tissue fluids percolating into the canal may provide nutri-
not be present in the apical part of the canal. In infected tive substrate. The apical 3 mm of the root canal system
cases, bacterial contamination may reach the most apical has been considered to be a critical zone in the treatment
part of the canal 1-3 and occasionally the periapex. 4-8 of infected root canal. 15
The purpose of shaping during instrumentation is to
create a canal configuration suitable for obturation. PROGNOSIS STUDIES
Ideally, instrumentation should terminate at a suitable In 1994, Stabholz et a116 summarized the factors
location, which is not necessarily the same for both influencing the success and failure based on a series of
vital and infected cases. If the termination is too short mainly retrospective studies. No influence was found
or too long, the outcome is negatively influenced. for most therapeutic factors, such as number of treat-
Obturation and restoration prevent the reinfection of ment sessions, type of interappointment intracanal
the pulp space by micro-organisms from the oral cavity, medicament, type of filling material, obturation tech-
to seal all portals of exit and to serve as a wound dressing nique, etc. All studies agreed, without exception, that
against which healthy tissue can oppose. Sealers are the extension of the filling material indeed influenced
toxic, and their irritative effects increase as the mate- the treatment outcome. 16 However, the analyses were
rial/tissue contact surface area increases. 9 Because obtu- based solely on radiographic findings, which may not
rating materials (particularly sealers) may elicit sensi- coincide with histologic healing. 17-19 In addition, no
tivity and immune responses when in contact with vital adequate statistical tests were applied to investigate the
tissues, 10 they should remain in the canal to minimize simultaneous influence of several potential factors on
contact surface and irritative effects. 11-14 Furthermore, treatment outcome. 2° However, these studies together
theoretically, a small contact surface may reduce the risk form a very large sample; the influence of other factors
of leakage as a result of less material/canal wall interface. may be similar in the subgroups of over-, under-, and
flush-extended root fillings. Therefore, the same
aLecturer.
bprofessor and Chairman, Departmentof CariologyEndodontology conclusion reached in all these studies is likely a
Pedodontology,AcademicCentre for DentistryAmsterdam(ACTA), correct observation: prognosis is decreased with over-
Amsterdam, The Netherlands. fill and with significant underfill.
cprofessor,Departmentof Endodontics, Universityof Iowa, College
of Dentistry,Iowa City, Iowa. ANATOMY OF THE APICAL CANAL
Received for publication Feb 2, 1999; returned for revision Mar 16
and June 15, 1999; acceptedfor publication July 10, 1999. The apical anatomy of the root canal system (Fig 1) is
Copyright© 2000 by Mosby,Inc. important in understanding the principles of root canal
1079-2104/2000/$12.00 + 0 7/151101618 treatment (RCT). The traditional classical concept of

99
100 Wu, Wesselink, and Walton ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2000

root canal

dentin

cementum
_ Apex

Fig 1. Concept of the apex. Distance between the 2 landmarks, the apical constriction (AC) and the apical
foramen (AF), and the true apex varies in each root considerably. The presence, location, and relationships of
the AC to the AF is more theoretical than actual.

this anatomy is from Kuttler. 21 He found that usually rate close to the AF but hopefully, not beyond.
the root canal narrowed toward the apex and expanded Obviously, this will often not be the outcome.
to form the apical foramen (AF). Further, the narrowest
part of the canal formed the apical constriction (AC), TERMINATION POINT WITH A VITAL PULP
just short of the AE However, in another publication, 22 With an irreversible pulpitis (vital pulp), bacteria (if
the "traditional" single AC was found in less than half present) are usually limited to the chamber. Instrumenta-
of the teeth. Frequently, the very apical portion of root tion apically is to remove the noninfected tissue and to
canal was tapered or parallel. 22 Other authorslS, 23 had shape the canal. For these cases, the favorable point to
suggested that often no AC is present, particularly with terminate instrumentation and to form an apical stop
apical pathosis and root resorption.15, 23 The classic appears to be 2 to 3 mm short of, rather than 0 to 2 mm
concept (Fig 1) is also that the AC forms the minor from, the apex. 12,28 This principle (partial pulpectomy)
foramen (or minor diameter)24; the most apical opening was originally proposed by Davis 29 in 1922. He
of the root canal is designated the AF or major foramen suggested preservation of vital pulp apically, often
or greater diameter. 24 In reality, in more than 60% of the referred to as the apical pulp stump. Following this prin-
canals, the AF is not located at the apex, and the ciple, a good success rate was obtained by Kerekes and
distance between the AF and the radiographic apex Tronstad 28 and by Sjrgren et al.12 Therefore, for vital
varies from 0 to 3.0 mm.21,22,z4-27 The conclusion is that cases, the biologic and clinical evidence indicates it is
the classic apical canal anatomy, as shown by Kuttler, 21 unnecessary to terminate the procedures close to the AF.
is more conceptual than actual. When the apical pulp stump remains, extrusion of
The AC is commonly advocated as the ideal termi- irritating filling materials into the periradicular tissues
nation for RCT, being a natural narrowing of the root may be prevented, thereby favoring apical healing. 14
canal and almost at the termination of the pulp. This Apparently, the reaction of the pulp stump to the filling
is supposedly where an apical stop is formed, against materials will not negatively influence the health of
which the obturation materials are packed. Because periapical tissues. The concept that the apical peri-
this constriction is usually not present, the AF may odontium should not be challenged with the extrusion
be a more useful landmark. The distance between the of root canal filling materials beyond the end of the
AC (when present) and the AF ranges from 0.5 to 1.0 canal is supported by many authors. 30
m m for teeth of different ages.21,22, 24-27 When the AF
is located, the position of the AC (if it exists) can be TERMINATION POINT FOR INFECTED
estimated; if the AC is not present, the preparation CANALS
and obturation will usually be within the confines of Infected canals likely differ from teeth with vital
the root. pulps. In addition to removal of necrotic tissue and
In fact, it is difficult to locate either the AC or the AF debris, an important goal is to reduce or eliminate
clinically. Usually visible radiographically is the root bacteria. Because it is unknown how many bacteria
apex. Although 0.5 to 1 mm short of the radiographic remaining in the apical portion of the root canal can
apex is commonly used as the termination point, this is be managed by host defenses, instrumentation length
only an estimate. It is an attempt to debride and obtu- should presumably not be shorter than the apical level
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Wu, Wesselink, and Walton 101
Volume 89, Number 1

"-:)." dentin
~'.{ debris

A
I II

Fig 2. Recapitulation to the working length with a small file. A, Dentin debris may shorten the working length
and plug the canal at and beyond the working length. B, Recapitulation with a small file will aid in maintaining
the full working length; the canal beyond the working length may still be plugged by debris.

of bacteria. Bacteria may remain sealed in the root- when treatment terminated short of 2 mm from, or was
filled canals of many radiographically successful beyond the radiographic apex. 12,28,35 When procedures
cases. 31 As long as there is no pathway of bacteria or were more than 2 m m short of the apex, a significant
bacterial by-products to the periapex, a periapical reduction in success rate was recorded. 12,26 An inter-
response will not develop. If an avenue is later estab- pretation is that the apical canal may harbor a critical
lished, a nutritional (substrate) supply will develop, count of microorganisms that would maintain periradic-
bacteria will proliferate and an inflammatory reaction ular inflammation. Thus, instrumentation is preferred to
may ensue. a level deep enough to remove or at least significantly
Canals with necrotic pulp tissue with or without peri- reduce these microorganisms.
radicular pathosis are treated as infected canals. % An During instrumentation, dentinal debris, which may
approach is to evaluate the correlation between the be infected, is produced and may remain within the
termination point and the success rate of infected apical canal or in the periapical tissues. 1 In the canal,
canals by using the data from only those cases with this debris may reduce the working length and may
pretreatment radiolucencies. These are likely the cases hinder repair. 36,37 In a study 37 of periradicular biopsies,
with infected canals32; the change in size of the lesion extruded dentin debris or other materials often was
after treatment is assessed radiographically. A definite associated with surrounding inflammation. These
correlation between the radiographic and histologic debris or materials were related to a history of RCT or
findings has been reported for the teeth with pretreat- apicoect0my. Why dentin chips cause periradicular
ment apical radiolucencies only. 33 Importantly, a tooth inflammation 36,37 should be further studied. Recapitu-
with no apical radiolucency before treatment may actu- lation to the working length only may maintain the
ally have an apical pathosis that is not radiographically working length but not remove the dentinal debris that
visible. 34 Therefore, information about the change in have plugged the canal beyond the working length (Fig
lesion size after the treatment may not be provided by 2). It presumably would be preferable to prevent plug-
the radiographs if the lesion remains invisible. Perhaps ging of dentinal debris in the apical portion of the canal,
this is why no definite correlation between the radi- although it is unknown whether this debris (infected or
ographic and histological findings could be found for uninfected) constitutes a significant irritant.
the teeth without pretreatment apical radiolucencies. 33 With the use of instrumentation, techniques that
The best success for treatment of teeth with necrotic involved a rotational motion, such as the balanced force,
pulps has been recorded when RCT was terminated at Canal Master U, Lightspeed and ProFile techniques 38,39
or within 2 m m of the radiographic apex (0 to 2 mm) for and frequent irrigation in sufficiently enlarged apical
infected canals with visible apical pathosis. However, canals 4° have been found to be efficient in reducing
statistically significantly lower success was recorded accumulated dentinal debris in the apical canal.
I02 Wu, Wesselink, and Walton ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2000

A n o t h e r technique to enlarge and clean the apical bacteremia often is the result of overinstrumentation of
canal is "apical clearing?' Parris et al,41 after step-back teeth with necrotic, b a c t e r i a l l y c o l o n i z e d pulp
filing, used successively larger files a few sizes larger spaces. 5° Although there is no definitive evidence that
than the master apical file with a reaming motion; this introducing bacteria or antigens from infected canals
technique did indeed enlarge and further debride the into the bloodstream causes systemic diseases, it would
apical canal with less debris accumulation. seem prudent to avoid this situation when possible.
One suggested approach to solve the problem is the
"apical patency" concept. This is using a very small size SUMMARY
file (10 or 15) to 1 m m longer than the final working Because most publications on outcomes are retro-
length in an attempt to remove the dentinal debris from spective, definitive conclusions are not possible. Based
the very apical portion of the canal. This concept is on current information, the apical termination point of
taught in 50% of the United States dental schools. 42 root canal treatment procedures seems to be an impor-
However, the efficacy o f using a small file to remove the tant influence on treatment outcomes. F o r teeth with
debris remains to be evaluated. Considering the apical vital pulps, leaving an apical pulp stump of up to 3 m m
canal anatomy, this approach seems unreasonable. If the is recommended. For the infected canals, the length of
patency file extends to the radiographic apex, 43 usually root canal instrumentation should ideally not be short of
the instrument will go beyond the A F because the A F is the level to which bacteria have contaminated; locating
usually located short of the apex. 21,22,25-27 The further the A F is of more importance, but it is difficult to
the deviation of the A F from the apex, the further the accomplish. The final length for a few cases in which
instrument will penetrate and damage apical periodon- root canal therapy has failed and the failure m a y be
tium. In addition, the small file will likely not remove related to infection in the very apical part of the canal,
significant amounts o f debris. Again, this apical patency is to the AF; admittedly, the exact level of the A F cannot
concept remains untested. be determined with certainty.
In conclusion, b a s e d on b i o l o g i c a l principles and
TERMINATION POINT FOR RETREATMENT experimental evidence, instrumentation or obturation
W h e n present, the AC is the narrowest diameter of should not extend beyond the apical foramen. These
the blood supply. Apically, the canal widens and m a y r e c o m m e n d a t i o n s m a y change as additional well-
have a richer b l o o d supply that m a y allow better controlled, outcome-assessment studies are published.
i m m u n e activities than in the pulp canal. However,
bacteria m a y s o m e t i m e s persist in the canal 44 and
survive b e y o n d the AC; a speculation is that these
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