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Apex and its significance in endodontics
- 2. ROOT APEX ANDITS SIGNIFICANCE IN ENDODONTICS Rocky John, MDS
- 3. CONTENTS • INTRODUCTION • DEVELOPMENTOF ROOT AND APEX • APICAL CLOSURE • APICAL ROOT ANATOMY • CEMENTO DENTINAL JUNCTION • APICAL FORAMEN • ACCESSORY CANALS • APICAL ENLARGEMENT • RESORPTION • PULPSTONES AND DENTICLES • ISTHMUS • ADVANCED IMAGING • OBTURATION TECHNIQUES • APICECTOMY • CONCLUSION • REFERENCES
- 4. INTRODUCTION • Achievement ofperfect seal at the apex is the goal of endo. therapy • Effective manipulation and obturation of apical 3rd is crucial. • KRONFELD in 1939 itself highlighted its importance. • Internal morphology of root apex varies from person to person • Poses a great challenge to successful endodontic therapy.
- 5. • HESS hadconducted an extensive study on the variations of root canals • This area is still under constant research work and it includes fracture of apical third, weeping canals, Immature foramina.
- 6. DEVELOPMENT OF ROOTAND APEX • Once CEJ is established, OEE proliferates downwards to form HERS • Determines shape and size of the root • Epithelial diaphragm stays in place while tooth moves occlusally. • Cementoblast cells differentiate from dental sac and deposits cementum.
- 8. APICAL CLOSURE • Knowledgeof the time of root completion and apical closure is mandatory for an effective endodontic therapy. • Apical closure plays a crucial role in the repair of inflamed pulp. • According to MORREES et al apical closure occurs early in females • Closure of maxillary posteriors is slightly later compared to mandibular teeth. • Young teeth have a funnel shaped opening at their apex.
- 9. APICAL ROOT ANATOMY •3 anatomic and histologic land marks Apical constriction (Postoperative discomfort generally greater when this area is violated by instruments or filling materials and the healing process may be compromised) Cementodentinal junction Apical foramen • According to KUTTLER, narrowest point is not at the apex but within the dentin prior to the start of cementum. • Minor diameter aka apical constriction.
- 12. • Morphologically complex •Therapeutically challenging • Prognostically important • Radiographically unclear • However, an endodontic therapy is almost always judged by the way the RC filling in the apical 1/3rd appears on a radiograph.
- 13. • According toKUTTLER all obturations must terminate at the minor constriction • It would serve as ―apical dentin matrix. • It is the physiologic foramen and provides bottle neck effect • Holds the sealer and filling material within the canal
- 14. CEMENTO-DENTINAL JUNCTION • Meetingpoint of pulp tissue and periodontal tissue • Location is highly variable • Not the same as the apical constriction • SMULSON et al observed that CDJ is appx 1mm from the apical foramen
- 15. APICAL FORAMEN • Fromthe apical constriction, the canal widens as it reaches the apical foramen • Funnel shaped • Hyperbolic • Morning glory
- 16. The mean distancebetween major and minor diameter • Younger individual-0.5mm • Older individual -0.67mm • Usually, the apical foramen opens 0.5 – 1.0 mm from the anatomical apex. • This distance is not always constant and may increase as the tooth ages because of the deposition of secondary cementum • KUTTLER demonstrated that diameter of apical foramen grows with age.
- 17. • Apical foramenmay be round, oval or elliptical, semilunar in shape. • Location and shape of the fully formed foramen vary in each tooth and in the same tooth at different periods of life.
- 18. • The apicalforamen is not always located in the centre of the root apex. • It may exit on the mesial, distal, labial or lingual surface of the root, usually slightly eccentrically.
- 19. MJOR et alfound variations in root apex • Accessory canals • Areas of resorptions • repaired resorption • Pulp stones • Secondary dentin • Dentinal tubules • Areas devoid of tubules • Fine tubular branches and microbranches
- 20.
- 21. ACCESSORY CANALS • Defectin epithelial root sheath • Failure in the induction of dentinogenesis • Presence of small blood vessels • More prevalent in the apical third
- 22. • Not significantin success/ failure of endo therapy • To be precise their role is not yet determined definitely • Percentage of failure due to unfilled lateral canals is small in clinical practice • Biological hard closure of lateral canal foramina after removal of infection is observed.
- 23. Apical Enlargement • Rootcanal system need to be enlarged sufficiently to remove debris proper irrigation to apical third of the canal • Larger instrument sizes allow proper irrigation significantly decrease remaining bacteria in the canal system
- 24. RESORPTION • Due toorthodontic tooth movement • Inflammation of Pulp Periapical Periodontal tissues Widens apical foramen, change in anatomy of root apex
- 25. • If radiographicallythere is no resorption of the root end or bone, shorten by 1.0 mm. • If periapical bone resorption is apparent, shorten by 1.5mm • Both root and bone resorptions are apparent, shorten by 2.0 mm.
- 26. • if thereis root resorption, the apical constriction is probably destroyed and hence the shorter length is taken. • If there is bone resorption, there is probably root resorption also though it may not be evident radiographically
- 27. PULP STONES/DENTICLES • 15%in apical third • Calcifications in apical 1/3rd should be tried to be negotiated with EDTA and thin files
- 28. ISTHMUS • In manyteeth with a fused root there is a web like connection between two canal • Kim et al. identified five types of isthmi that can be found on a bevelled root surface.
- 29. • Type 1:Classified as an incomplete isthmus is a barely traceable communication between two canal. • Type 2: complete isthmus can be straight line between two canals. C-shaped connection. • Type 3: It is complete but very short connection between two canals. • Type 4: complete or incomplete, but it connect three or more canals. • Type 5: Do not have any visible connection even after being stained. (The dilemma root surface of this type is Whether to treat it as isthmus to connect the canal or to treat the orifice only.) CLASSIFICATION (KIM et al)
- 30. • THIN PINCHEDAPEX: careful about perforations • BULBOUS APEX: Due to hypercementosis (constriction significantly shorter compared to normal teeth) • BLUNDERBUSS APEX: newly formed teeth
- 31. • Apexogenesis incase of vital pulp: pulpotomy • Apexification: (non vital pulp) calcium hydroxide, MTA, Tricalcium phosphate etc required period:6-24 months, 3 months recall. After apexification, obturation is done as usual.
- 32.
- 33. OBTURATION TECHNIQUES • WARMCOMPACTION • CONTINUOUS WAVE COMPACTION • THERMOPLASTICIZED GP INJECTION • McSPADDEN THERMOMECHANICAL CONDENSATION • CHEMICALLY PLASTISIZED GP
- 34. WARM VERTICAL COMPACTION(Schilder) •HEAT CARRIER • SYBRON ENDO • 80C HEAT • APEX 40-42C • DISADVANTAGES: TIME CONSUMING • RISK OF VERTICAL FRACTURE • OVERFILLING CAN’T BE RETRIEVED
- 35. CONTINUOUS WAVE COMPACTION •Variation of warm vertical compaction introduced by Buchanan
- 36. THERMOPLASTICIZED GP INJECTION •GP HEATED TO 70 C • INJECTED USING PERIPRESS SYRINGE • OBTURA III
- 37. McSPADDEN THERMOMECHANICAL CONDENSATION (1979) •HANDPIECE DRIVEN COMPACTOR (6000-7000RPM) • INVERTED H FILE • FRICTIONAL HEAT PLASTICIZES GP
- 38. CHEMICALLY PLASTISIZED GP •CHLOROFORM • EUCALYPTOL • XYLOL
- 39. APICECTOMY • Resection ofthe root close to 90 degrees to the long axis as possible • Reduce the number of exposed dentinal tubules and to ensure access to all the apical anatomy. • If possible, at least 3mm of root end should be resected with a rotating bur (using saline or water coolant).
- 40.
- 41. • The root-endpreparation should be isolated from fluids, including blood. A suitable haemostatic agent should be placed in the bony crypt. • The root-end filling material should be compacted into the cavity with a small plugger. • A biologically compatible material is used. • MTA, glass ionomer, composite resin, ethoxybenzoic acid (EBA) etc
- 42. CONCLUSION • The morphologicalvariation and technical challenges involved in treatment of the apical third is infinite. • Proximity of apices of certain teeth are in close association with maxillary sinus, inferior alveolar nerve. • Inadequate attention may lead to serious complication. • The root apex is morphologically, therapeutically a challenging zone and prognostically an important but unfortunately unclear area. • So endodontist should have a detailed knowledge for a successful therapy.
- 43. References • Endodontics- Ingle •Pathways of pulp- Cohen • Grossman’s Endodontic practice • Oral Histology- Tencate • Oral Histology- Orban
- 44. • Guidelines forSurgical Endodontics Glynis E Evans et al • Chaudhari A et al, Significance of Apical Third: A Review, Sch. J. App. Med. Sci., 2014; 2(5B):1613-17 • DCNA