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

99
100 Wu, Wesselink, and Walton
root canal
dentin
cementum
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
the root canal narrowed toward the apex and expanded
to form the apical foramen (AF). Further, the narrowest
part of the canal formed the apical constriction (AC),
just short of the AE However, in another publication, 22
the "traditional" single AC was found in less than half
of the teeth. Frequently, the very apical portion of root
canal was tapered or parallel. 22 Other authorslS, 23 had
suggested that often no AC is present, particularly with
apical pathosis and root resorption.15, 23 The classic
concept (Fig 1) is also that the AC forms the minor
foramen (or minor diameter)24; the most apical opening
of the root canal is designated the AF or major foramen
or greater diameter. 24 In reality, in more than 60% of the
canals, the AF is not located at the apex, and the
distance between the AF and the radiographic apex
varies from 0 to 3.0 mm.21,22,z4-27 The conclusion is that
the classic apical canal anatomy, as shown by Kuttler, 21
is more conceptual than actual.
The AC is commonly advocated as the ideal termi-
nation for RCT, being a natural narrowing of the root
canal and almost at the termination of the pulp. This
is supposedly where an apical stop is formed, against
which the obturation materials are packed. Because
this constriction is usually not present, the AF may
be a more useful landmark. The distance between the
AC (when present) and the AF ranges from 0.5 to 1.0
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
estimated; if the AC is not present, the preparation
and obturation will usually be within the confines of
the root.
In fact, it is difficult to locate either the AC or the AF
clinically. Usually visible radiographically is the root
apex. Although 0.5 to 1 mm short of the radiographic
apex is commonly used as the termination point, this is
only an estimate. It is an attempt to debride and obtu-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2000
_ Apex
rate close to the AF but hopefully, not beyond.
Obviously, this will often not be the outcome.
TERMINATION POINT WITH A VITAL PULP
With an irreversible pulpitis (vital pulp), bacteria (if
present) are usually limited to the chamber. Instrumenta-
tion apically is to remove the noninfected tissue and to
shape the canal. For these cases, the favorable point to
terminate instrumentation and to form an apical stop
appears to be 2 to 3 mm short of, rather than 0 to 2 mm
from, the apex. 12,28 This principle (partial pulpectomy)
was originally proposed by Davis 29 in 1922. He
suggested preservation of vital pulp apically, often
referred to as the apical pulp stump. Following this prin-
ciple, a good success rate was obtained by Kerekes and
Tronstad 28 and by Sjrgren et al.12 Therefore, for vital
cases, the biologic and clinical evidence indicates it is
unnecessary to terminate the procedures close to the AF.
When the apical pulp stump remains, extrusion of
irritating filling materials into the periradicular tissues
may be prevented, thereby favoring apical healing. 14
Apparently, the reaction of the pulp stump to the filling
materials will not negatively influence the health of
periapical tissues. The concept that the apical peri-
odontium should not be challenged with the extrusion
of root canal filling materials beyond the end of the
canal is supported by many authors. 30
TERMINATION POINT FOR INFECTED
CANALS
Infected canals likely differ from teeth with vital
pulps. In addition to removal of necrotic tissue and
debris, an important goal is to reduce or eliminate
bacteria. Because it is unknown how many bacteria
remaining in the apical portion of the root canal can
be managed by host defenses, instrumentation length
should presumably not be shorter than the apical level
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
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-
filled canals of many radiographically successful
cases. 31 As long as there is no pathway of bacteria or
bacterial by-products to the periapex, a periapical
response will not develop. If an avenue is later estab-
lished, a nutritional (substrate) supply will develop,
bacteria will proliferate and an inflammatory reaction
may ensue.
Canals with necrotic pulp tissue with or without peri-
radicular pathosis are treated as infected canals. % An
approach is to evaluate the correlation between the
termination point and the success rate of infected
canals by using the data from only those cases with
pretreatment radiolucencies. These are likely the cases
with infected canals32; the change in size of the lesion
after treatment is assessed radiographically. A definite
correlation between the radiographic and histologic
findings has been reported for the teeth with pretreat-
ment apical radiolucencies only. 33 Importantly, a tooth
with no apical radiolucency before treatment may actu-
ally have an apical pathosis that is not radiographically
visible. 34 Therefore, information about the change in
lesion size after the treatment may not be provided by
the radiographs if the lesion remains invisible. Perhaps
this is why no definite correlation between the radi-
ographic and histological findings could be found for
the teeth without pretreatment apical radiolucencies. 33
The best success for treatment of teeth with necrotic
pulps has been recorded when RCT was terminated at
or within 2 m m of the radiographic apex (0 to 2 mm) for
infected canals with visible apical pathosis. However,
statistically significantly lower success was recorded
Wu, Wesselink, and Walton 101
when treatment terminated short of 2 mm from, or was
beyond the radiographic apex. 12,28,35 When procedures
were more than 2 m m short of the apex, a significant
reduction in success rate was recorded. 12,26 An inter-
pretation is that the apical canal may harbor a critical
count of microorganisms that would maintain periradic-
ular inflammation. Thus, instrumentation is preferred to
a level deep enough to remove or at least significantly
reduce these microorganisms.
During instrumentation, dentinal debris, which may
be infected, is produced and may remain within the
apical canal or in the periapical tissues. 1 In the canal,
this debris may reduce the working length and may
hinder repair. 36,37 In a study 37 of periradicular biopsies,
extruded dentin debris or other materials often was
associated with surrounding inflammation. These
debris or materials were related to a history of RCT or
apicoect0my. Why dentin chips cause periradicular
inflammation 36,37 should be further studied. Recapitu-
lation to the working length only may maintain the
working length but not remove the dentinal debris that
have plugged the canal beyond the working length (Fig
2). It presumably would be preferable to prevent plug-
ging of dentinal debris in the apical portion of the canal,
although it is unknown whether this debris (infected or
uninfected) constitutes a significant irritant.
With the use of instrumentation, techniques that
involved a rotational motion, such as the balanced force,
Canal Master U, Lightspeed and ProFile techniques 38,39
and frequent irrigation in sufficiently enlarged apical
canals 4° have been found to be efficient in reducing
accumulated dentinal debris in the apical canal.
I02 Wu, Wesselink, and Walton
A n o t h e r technique to enlarge and clean the apical
canal is "apical clearing?' Parris et al,41 after step-back
filing, used successively larger files a few sizes larger
than the master apical file with a reaming motion; this
technique did indeed enlarge and further debride the
apical canal with less debris accumulation.
One suggested approach to solve the problem is the
"apical patency" concept. This is using a very small size
file (10 or 15) to 1 m m longer than the final working
length in an attempt to remove the dentinal debris from
the very apical portion of the canal. This concept is
taught in 50% of the United States dental schools. 42
However, the efficacy o f using a small file to remove the
debris remains to be evaluated. Considering the apical
canal anatomy, this approach seems unreasonable. If the
patency file extends to the radiographic apex, 43 usually
the instrument will go beyond the A F because the A F is
usually located short of the apex. 21,22,25-27 The further
the deviation of the A F from the apex, the further the
instrument will penetrate and damage apical periodon-
tium. In addition, the small file will likely not remove
significant amounts o f debris. Again, this apical patency
concept remains untested.
TERMINATION POINT FOR RETREATMENT
W h e n present, the AC is the narrowest diameter of
the blood supply. Apically, the canal widens and m a y
have a richer b l o o d supply that m a y allow better
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
bacteria are related to R C T failures. 1 It seems that it
would be preferable to clean the canal to the A F in
retreatment; the downside is the possibility of overin-
strumentation, which would force materials and debris
into periradicular tissues.
In order to reduce the introduction of irritants into the
periapex, a suggestion is to clean the coronal part of the
root canal first with a step-down or crown-down
sequence 45 with copious irrigation. However, instrumen-
tation extended beyond the radiographic apex, which
certainly would have its apical terminus beyond the AF,
has been found to hinder apical healing significantly.4648
Although instrumentation to the A F is suggested for
some failure cases, usually the apical stop should be
created at 1 to 2 m m short of the A F to confine the instru-
ments, irrigants, and obturants to the canal space.
SYSTEMIC CONSIDERATIONS
Concerns have recently been raised relative to the
impact o f oral conditions on systemic health. 49 The
impact may be by bacterial or immunogenic seeding of
distant organs or tissues v i a the vascular ( b l o o d or
l y m p h a t i c ) system. It has been d e m o n s t r a t e d that a
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2000
bacteremia often is the result of overinstrumentation of
teeth with necrotic, b a c t e r i a l l y c o l o n i z e d pulp
spaces. 5° Although 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.
SUMMARY
Because most publications on outcomes are retro-
spective, definitive conclusions are not possible. Based
on current information, the apical termination point of
root canal treatment procedures seems to be an impor-
tant influence on treatment outcomes. F o r teeth with
vital pulps, leaving an apical pulp stump of up to 3 m m
is recommended. For the infected canals, the length of
root canal instrumentation should ideally not be short of
the level to which bacteria have contaminated; locating
the A F is of more importance, but it is difficult to
accomplish. The final length for a few cases in which
root canal therapy has failed and the failure m a y be
related to infection in the very apical part of the canal,
is to the AF; admittedly, the exact level of the A F cannot
be determined with certainty.
In conclusion, b a s e d on b i o l o g i c a l principles and
experimental evidence, instrumentation or obturation
should not extend beyond the apical foramen. These
r e c o m m e n d a t i o n s m a y change as additional well-
controlled, outcome-assessment studies are published.
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Reprint requests:
M-K Wu, MD, MSD, PhD
Department of Cariology Endodontology Pedodontology
Academic Centre for Dentistry Amsterdam (ACTA)
Louwesweg 1
1066 EA Amsterdam, The Netherlands
M.Wu@acta.nl