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Transcript of Manejo Del Tercio Apical en PowerPoint
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Management ofthe Apical Third
The greatest enemy of truth is
very often not the deliberate,
contrived and dishonest, but themyth persistent, persuasive, and
unrealistic.
We enjoy the comfort of opinion
without the discomfort of
thought. John F. Kennedy
How We Manage
the Apical Third
Does it matter?
Apical Third Histology Historical Concepts
The CDJ as a dividing line is
imaginary (Coolidge, 29) Canals should be filled to the CDJ
(Skillen, 30)
Canals should be slightly overfilled
(Blayney, 27)
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Apical Third Anatomy
Classic Concept
Kuttler 55
Reality
Dummer 84; Ainamo & Le 68
Madsen et al 00; Meder et al 09
Kuttler JADA 1955
(A myth?)
Apical Morphology of Maxillary Molars
Using Microcomputerized Tomography
Meder-Cowherd L, Williamson A, Johnson W
In Preparation for Publication, J Endod 2010
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Materials and Methods
Shape of apical canal anatomy determined
Generated micro-computerized 3-D images Analyzed maxillary molar palatal roots
Selected images giving best view of apical canal
Analyzed by trained and blinded evaluators
Determined shape of apical canal anatomy
Categorized into configuration groups
Results
Apical anatomy highly variable
Several shapes of apical constriction
Parallel 35%
Single 18%
Tapering (Classic) 15%
Flaring 18%
Delta 12%
Frequent deviation of foramen from apex
Anatomy of Structures in the
Apical Region of the CanalA Histologic Evaluation
R. Madsen
L. Baldassari-Cruz
R. Walton(Abstract) J Endod 2000
Materials and Methods
Teeth and apical tissues removed from cadavers
Histologically prepared
Longitudinal sections to include apical 1/3 of canal
Determined were:
Location of apical foramen, apical constriction
Anatomy of apical constriction
Relationship of CDJ with apical constriction
Comparison with Kuttlers findings and diagram
Results Apical Constriction
Frequently not present
When present, shape and canal level variable
Cemento-Dentinal Junction Levels highly variable
Difficult to interpret
No specimen matched Kuttlers diagram
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Multiconstricted Flared
Apical anatomy often altered because of
apical pathosis and root resorptionIn Summary:
Kuttlers concept diagram likely does not occur
When present, the apical constriction is highly
variable
Frequently, there is no constriction
There is no clinical technique to evaluate presence
of constriction or shape of apical anatomy
The apical constriction should not be used as a
landmark for C&S or obturation
Apical Canal Anatomy
The apical few millimeters is variable inshape in cross-section
Many apical canals are flattened(ribbon-shaped)
May be multiple foramina
Frequent deviation from apex
Gani & Visvisian JOE 1999
Wu et al OOOOE 2000
Soma et al IEJ 2008
Martos et al IEJ 2009 Ganni and Visvisian 99; Wu 00
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Apical Canal Structure Marked variations
Accessory canals, resorptions, repair,
pulp stones, irregular secondary
dentin
Cementum-like tissue on canal walls
Mjr et al IEJ, 2001
Apical Third Histology
Classic Concept
Reality
Aberrations in the Apical Third
Frequency
Can they be debrided?Can they be obturated?
Does it matter?
Lateral Canals
Frequency
Can they be debrided?Can they be obturated?
Does it matter?
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Frequency and Location
Frequency high
Most in posterior teeth
Predominance in apical 1/3
Degerness and Bowles J Endod 2008
Apical Delta
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Can Lateral Canals be
Obturated in the Apical Third?
Canals prepared thenobturated with Schildertechnique
Roots were cleaned
Very few lateral canals filledwith gp and/or sealer
Venturi et al IEJ 36:54, 2003
Are Lateral Canals and Apical
Ramifications Debrided and Filled?
Apparently not
Teeth with RCT extracted
Roots prepared histologically
LCs and ARs examined for tissue, obturating
materials and bacteria
Results: LCs and ARs not debrided and
seldom contained obturating material
Ricucci, Siqueira. J Endod 36: 1, 2010
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Does It Matter If Lateral Canals are
Debrided and Obturated?
Apparently not
Block sections of apical regions in root-filledteeth were examined in cadaver jaws
All roots had lateral canals
No lateral canals contained obturatingmaterial
No relationship was detected betweenunfilled lateral canals and the status ofinflammation at the periapex
Barthel, Zimmer, Trope. J Endod 30:75, 2004
Intracanal Isthmi
FrequencyCan they be debrided?
Can they be obturated?
Does it matter?
Apical Patency
What is it?
What is the technique based upon? What are the advantages?
What are the disadvantages?
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How will small patency files behave?
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Patency File and Apical
Transportation
#s 10, 15, 20 and 25 patency files Precurved SS and NiTi hand files
Files used sequentially
Transportation seen with each file
size
Goldberg & Massone J Endod 28:510, 2002
Effect of Maintaining Apical Patency
on Canal Transportation
Compared different preparation techniques
Lightspeed rotary with and without patency files Balanced force hand with and without patency
Results:
All techniques produced transportation
No difference between groups
Tsesis et al IEJ 2008
Apical Patency: Other considerations?
Post-treatment pain? No effect
Arias et al J Endod 2009
Success rate? Not determined
Tissue damage?
Not determined, however
Updated recommendations for managing
the care of patients receiving oral
bisphosphonate therapy. JADA 2009
For endodontic procedures:
Manipulation beyond the apex is not
recommended
Apical Patency in Summary:
Has no biological rationale
Likely
does not accomplish the stated objectives
damages periapical tissues
does not improve outcomes
Has no effect on postreatment pain
Aspects of Apical Third
Preparation
Apical Clearing
Size of Preparation
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Does Increased Enlargement Reduce
Bacteria and Improve Debridement?
Yes Tan & Messer. JOE 2002
Card et al. JOE 2002
Usman et al. JOE 2004
Baugh & Wallace. JOE 2005
Heish et al. IEJ 2007
No (when initially to a larger size) Coldero & Saunders. IEJ 2002
Bacteria in the apical third
Before
Oval Canal Necrotic
Debris
After
Round Canal Clean and
Ready for
Obturation
Apical Clearing
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Effectiveness of Apical
Clearing: Histologic and
Morphologic Evaluation
Parris J, Wilcox L, Walton R J Endod 20:219, 1994
Apical Clearing Procedure
Final apical preparation (enlargement)
Irrigant present in canal
Files 3-4 sizes larger than MAF rotated at WL
Canal irrigated
Canal dried with paper points
Final apical reaming (Dry Reaming)
Largest file rotated at WL
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Possible Advantages of Apical
Clearing
Maximize debridement
Deeper penetration of irrigating
needle/solution
Increase size of apical preparation
Improved obturation
Objectives
Debris removal and walls planed
Apical transportation
Compare effectiveness of step-backwithout apical clearing vs. step-
back with apical clearing for:
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Conclusions
Apical clearing resulted in better
debridement
Apical transportation was found in
both groups; more in the apically
cleared group
Why is there minimal transportation?
What About the Smear Layer?
Studies generally favor removal
NaOCl alternated with EDTA best
Deep needle penetration
Special irrigating devices?
Apical third less predictable removal
Messer
Uroz-Torres et al. J Endod, 2010
Violich, Chandler. Int Endod J, 2010
What About Apical Preparation Size?
R Madsen
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Root Canal TreatmentRoot Canal Treatment
Looks Good?Looks Good?
Length OKLength OK
Shape OKShape OK
Why did it fail?Why did it fail?
LetLets extract and sections extract and section------
Courtesy Dr S Senia
Mesial root - 1 mm from apex
necrotic tissue and debris
Mesial root - 2 mm from Apex Distal Root - Foramen
Poor obturationPoor obturation
Distal Root - 1 mm from Apex
Necrotic tissue and debris
Canal notCanal not
instrumented to theinstrumented to the
correct diametercorrect diameter
Distal Root - 3 mm from Apex
Necrotic Tissue and Debris
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Nair R. In: Pathways to the Pulp 2006
Working Length
ConsiderationsPrognosis
Periapical Response
Post-treatment Symptoms
Systemic Impact
Considerations
PrognosisPrognosis
Periapical Response
Post-treatment Symptoms
Systemic Impact
PrognosisExtrusion of
Obturating Material
An irritantRelated to decreased
success Nair R. Pathways of the Pulp,
2006
Torabinejad & Siggurdson.
Endodontics: Principles and
Practice 2009
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Determining Optimal Obturation
Length: A Meta-analysis of Literature
Short of the radiographic apex
had better success than long
Preferable to err on the short side
than be long (uncertain about
sealer extrusion only)
Schaeffer, White, Walton. J Endod 2005
Evid Based Dent 2005
Prognosis
Long-term Studies Show: Optimal result: end preparation and
obturation within radiographic apex
Too short, success rate drops
Beyond apex, an even poorer result
Gutmann & Witherspoon, Pathways to
the Pulp, 8th ed. 2002
Prognosis
Success rate of endodontic treatment of teeth with
vital and nonvital pulps. A meta-analysis
No difference between vital and non-vital pulps
Failure rate greater with a lesion present
Success much lower with obturation overextension than
with flush or underextension
Conclusion: The root canal should be filled to within
2mm of the radiographic apex.
Kojima K et al. OOOOE 97: 95, 2004
Considerations
Prognosis
PeriapicalPeriapical ResponseResponsePost-treatment Symptoms
Systemic Impact
Tissue Injury and Inflammation
from:
Instruments
Irrigants
Medicaments
Obturating Materials
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Termination of Preparation and
Obturation
Short of the radiographic apex
Short of the apical foramen Review: Ricucci, Langeland, Int Endo J, 1998
Termination of Preparation and
Obturation
Vital pulp: 1-3 mm short Necrotic pulp: 0-2 mm short
Wu, Wesselink, Walton OOOOE 2000
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Techniques of Canal Preparation
StandardizedFlaring
Stepback
Crown-down
Rotary
Debridement of the Apical Third
Hand tends to debride better than
rotaryApical canals are variable in shape
Uninstrumented, undebrided areasare common
Ahlquist et al IEJ, 2001
Barbizam et al JOE, 2002
Wu & Wesselink IEJ, 2001
Rdig et al IEJ, 2002
Shaping of the Apical Third
All techniques tend to transport
Factors (curvature, size, shape) are
important
Different instruments and
techniques cause variability Peters et al J Endod, 2001
Imura et al J Endod, 2001
Ahlquist et al Int Endod J, 2001
Hartmann et al J Endod, 2007
Moore et al Int Endod J, 2009
ObturationLength
Technique
Cold Lateral
Warm Vertical
Other
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Tissue Reaction to Obturation
Short of the apex little
responseBeyond the apex
Inflammation
Delayed healing
Ricucci & Langeland, IEJ, 1998
Guttmann & Witherspoon, 2002
Extrusion of Debris
Compared NiTi rotary (Lightspeed & ProFile
.04) and stainless steel hand (step-back &balanced force)
Determined amount of debris extrusion
All techniques produced apical debris
Overall, NiTi rotary extruded the least
Reddy S & Hicks L. JOE, 1998
Considerations
Prognosis
Periapical Response
PostPost--treatment Symptomstreatment Symptoms
Systemic Impact
Post-Canal Preparation Symptoms
Canal preparation with either SS hand or NiTi
rotary
Determined pain levels and pain incidence
No difference in the groups
Aqrabawi J et al. J Dent 2006
Post-Obturation Symptoms
48% reported symptoms after
obturation
10% or less significant symptoms Overfill (no lesion) more pain
Harrison et al. JOE, 1983
Considerations
Prognosis
Periradicular Response
Post-treatment Symptoms
Systemic ImpactSystemic Impact
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Systemic Considerations
Oral Microbes and Disease
Bacteremia
Inducing Bacteremia
Factors that produce
bacteremia
Necrosis
Over-instrumentation
Impact
Bacterial Extension
Pulp Necrosis
Apical Foramen
Short Close
Beyond
Bender et al, Oral Surg, 60
Baumgartner et al, JOE, 76
Overinstrumentation and
Bacteremia
Periradicular Contamination Gutierrez et al., 1999
Intracanal Bacteria in Blood Debelian and Tronstad, 1998
Ayub et al IEJ 2007
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Updated recommendations for managing
the care of patients receiving oral
bisphosphonate therapy. JADA 2009
For endodontic procedures:
Manipulation beyond the apex is not
recommended
In Conclusion
Apical canal anatomy and histology are
variable and indeterminable, clinically
Instruments, materials and chemicals
should be confined to the canal
Conclusions (continued)
Lengths should be 1-3 mm short of the apex
Aberrations are inconsistently debrided
Debris in the apical canal preparation should be
reduced before obturation
Apical canal preparation should be at least #40
There is no superior instrumentation technique
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Periapical Tissue Injury and
Inflammation Occurs from:
Instruments
Irrigants
Medicaments
Obturating Materials
Termination of Preparation and
Obturation
Vital pulp: 1-3 mm short
Necrotic pulp: 0-2 mm short
Termination of Preparation and
Obturation
Short of the radiographic apex
Short of the apical foramen
Bacterial Extrusion Beyond the
Apex Will Produce:
Periapical inflammation
And May Produce:
Systemic disease
FinallyWe need more definitive
information based on:
Scientific data
Evidence-based research
Outcomes assessment
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Good clinical decisions require
scientific accuracy to avoid bias
Clinical significance is the
consideration of risk vs. benefit
Important outcomes (success) of
therapy are measured by a
combination of evidence-based
criteria, clinical judgment and
common sense.