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Introduction

The root apex is of interest to endodontists because the stages of


root development and the type of tissue present within the roots of teeth are
significant to the practice of endodontics.
Also, appreciable knowledge of the morphology of the root apex
and its variance, ability to interrupt it correctly in radiogaphs, and to felt it
through tactile sensation during instrumentation are essential for an
effective rendering of the treatment of root canals.
Achievement of a perfect oral at the apex using an invert filling
material is the ultimate goal for every endodontist.
Existence of apical 3
rd
:
1. Development of the root apices.
2. ulpal tissue within.
!. "orphology and variance.
#. Ability to interrupt correctly.
$. %ell it through tactile sensation during instrumentation.
All essential for a successful treatment of the root canal.
1
Development of the root apex:
The development of the root begins after the enamel and
the dentin formation has reached the future cemento&enamel
'unction.
The enamel organ play an important part in the
development by forming (ertwig)s epithelial root sheath, which
molds the shape of the roots and initiates radicular dentin formation.
(ertwig)s root sheath consists of the outer and inner
enamel epithelial only *and therefore it does not include the stratum
intermedium and stellate reticulum+.
The cells of the inner layer remain short and normally do
not produce enamel.
,hen these cells have induced the differentiation of
radicular cells into odontoblasts and the first layer of dentin has
been laid down, the epithelial root&sheath loses its structural
continuity and its close relation to the surface of the rooth.
-ts remnants persist as an epithelial network of strands or
tubules near the external surface of the root.
These epithelial remnants are found in the periodontal
ligament of erupted teeth and are called .cell rests of malasse/0.
2
There is a pronounced difference in the development of (ertwig)s
epithelial root sheath in teeth with one root and in those with 2 or more
roots.
rior, to the beginning of root formation, the root sheath
forms the epithelial diaphragm.
The outer and inner enamel epithelia bind at the future
cement&enamel 'unction into a hori/ontal plane narrowing the wide
cervical opening of the tooth germ.
The plane of the diaphragm remains relatively fixed
during the development and growth of the root.
The proliferation of the cells of the epithelial diaphragm
is accompanied by proliferation of the cell of the connective tissue
of the pulp, which occurs in the area ad'acent to the diaphragm.
The difference of odontoblasts and the formation of
dentin follow the lengthening of the root&sheath.
The free&end of the diaphragm does not grow into the
connective tissue, but the epithelial proliferates coronally to the
epithelial diaphragm.
!
At the same time the connective tissue of the dental sac
surrounding the root&sheath proliferates and divides the continous
double epithelial layer into a network of epithelial strands.
The epithelium is moved away from the surface of the
dentin so that connective tissue cells come into contact with the
outer surface of the dentin and differentiate into cementoblasts that
deposit a layer of cementum onto the surface of the dentin.
The rapid se1uence of proliferation and destruction of
(ertwig)s root sheath explains the fact that it cannot be seen as a
continuous layer on the surface of the developing root.
-n the last stages of root development, the proliferation of
the epithelium in the diaphragm lags behind that of the pulpal
connective tissue.
The wide apical foramen is reduced first to the width of
the diaphragmatic opening itself and later is further narrowed by
apposition of dentin and cementum to the apex of the root.
Differential growth of the epithelial diaphragm in multi&rooted teeth
causes the division of the root trunk into 2 or ! roots.
During the general growth of the enamel organ the
expansion of its cervical opening occurs in such a way that long
tongue&like extensions of the hori/ontal diaphragm develop.
#
2 such extensions are found in the germs of lower molars
and ! in the germs of upper molars.
2efore division of the root trunk occurs, the free ends of
these hori/ontal epithelial flaps grow towards each other and fuse.
The single cervical opening of the coronal enamel organ
is then divided into 2 or ! openings.
3n the pulpal surface of the dividing epithelial bridges,
dentin formation starts.
3n the periphery of each openings, root development
follows in the same way as described for single&rooted teeth.
Type - 4 A single canal extends from the pulp chamber to the apex.
Type -- 4 2 separate canals leave the pulp chamber and 'oin short of
the apex to form are canal.
Type --- 4 3ne canal leaves the pulp chamber, divided into 2 within
the root, and then to exist as one canal.
Type -5 4 2 separate and distinct canals extend from the pulp chamber
to the apex.
Type 5 4 3ne canal leaves the pulp chamber and divides short of the
apex into 2 separate and distinct canals with separate apical
foramina.
$
Type 5- 4 Two separate canals leave the pulp chamber, merge in the
body of the root and redivide short of the apex as 2 distinct
canals.
Type 5-- 4 3ne canal leaves the pulp chamber, divides and then
regions within the body of the root and finally redivides
into 2 distinct canals short of the apex.
Type 5--- 4 ! separate and distinct canals extend from the pulp chamber
to the apex.
6enerally, the roots have a single apical foramen and a single canal
*Type -+. (owever, it is not uncommon for other canal complexities to be
present and exit the root as one, two or three apical canals *Type --&5---+.
7lassification of the root apex is essential for endodontic practice,
particularly when dealing with pulp&involved or pulpless teeth of children
and young persons.
As a general rule, as root&apex is completely formed about 2&! years
after the eruption of the tooth.
The following table gives the approximate time in years of eruption
of the teeth and calcification of the root apices.
7.-. 8.-. 7used 1
st
" 2
nd
"
1
st
" 2
nd
"
9ruption :&; <&= 1>&12 =&11 11&12 $&< 12&1!
7alcification 1>&12 11&12 1!&1# 12&1# 1!&1# 1>&11 1$&1:
:
-n young incompletely developed teeth the apical foramen is funnel
shaped with the wider portion extending outward. The mouth of the funnel
is filled with periodontal tissue that is later replaced by dentin and
cementum.
Any in'ury occurring before its closure may result in changes that
may lead to formation of the blunderbuss canal.
?uccessful repair of inflamed dental pulps in teeth with
incomplete apical root closure is enhanced compared to that of teeth
with completed root formation. ossibly because of the unrestricted
metabolism in the former group.
Thus pulp capping and pulpotomy procedures have a
better chance for successful resolution in teeth with open apexes.
3nce root end formation has been completed, complete endodontic
therapy has a better prognosis than pulp capping or pulpotomy
procedures.
7- 8- 7 " " 2
nd
"
:&; <&= 1>&12 =&11 $&< 12&1#
1>&12 11&12 1!&1# 12&1# 1>&1# 1$&1:
Apical foramen and apical constriction:
8ocation and shape of the fully&formed foramen vary in each tooth
and in the same tooth at different periods of life.
<
Awareness of these is considered important for effective rendering
of the treatment. The foramen can change in shape and location beucase of
functional influences on the tooth for e.g. tongue pressure, or nasal
pressure, mesial drift. 7ementum resorption curve on the wall of the
foramin fastest for the force apposition on the wall nearest the net result is
the development of the foramen away from the tissue apex.
-t is a popular misconception that the apical foramen coincides with
the anatomical apex of the tooth. This is an infre1uent&occurrence and
usually the apical foramen opens >.$&1mm from the anatomical apex.
This distance is not&always constant and may increase as
the tooth ages because of the deposition of 2@ cementum on the
outer surface of the root and 2@ dentin on the walls of the root canal.
The apical foramen is not always located in the center of
the root apex.
-t may exist on the mesial, distal, labial or lingual surface
of the rot, usually slightly eccentrically.
8evy and 6laft *1=<>+ found in their study that the deviation
occurred more commonly on the buccal or lingual aspect than on the
mesial or distal side.
;
An endo instrument protruding beyond the foramen on
either buccal or lingual A palatal aspect cannot be discerned in x&rays
and may give a deceptive picture as true placement upto the apex.
?tudies *6reen, 1=$$, 1=$:, 1=:>+ have shown that the
ma'or apical foramina are situated directly at the apexes more
fre1uently in the maxillary centrals, laterals, cuspids and first
premolars and in the mandibular 2
nd
pre molars.
-n the maxillary molars and all the mandibular tooth with
the exception of the 2
nd
premolar, the main apical foramina coincide
with apices less fre1uently.
Location and shape of apical foramen:
5aries with different teeth and in same teeth.
-n relation to anatomical apex4 "any believe that the A% located at
the anatomic apex but it is not so always. A% located >.$&1mm away from
anatomical apex.
Distance may vary with age either due to 4 -ncreased dentin,
increased cementum deposition.
-n maxillary 7lass -, 7lass --, 1
st
premolar and mandibular
2
nd
premolar A% open may coincide and apex.
=
2ut in all mandibular teeth *except mandibular 2
nd
premolar+ and maxillary molars opening does not coincide with
anatomical apex.
"any believes the apical foramen to open at the center of
the root apex but not so can open either ", D, 2, 7 more often 2A8.
Apical Constriction:
The apical foramen is not always the most constricted portion of the
root canal.
%re1uently the narrowest portion of the root canal, termed
the .apical constriction0 occurs about >.$&1mm from the apical
foramen.
Again, the portion of the apical constriction varies with
age as deposits of 2
nd
dentin, within the root canal, site of the
constriction away from the apex.
-deally, the root&filling should stop at this constriction as it would
serve as Bapical dentin matrix) *an artificially produced ledge in the apical
root canal, against which gutta&percha could be compacted without the fear
of its protrusion into the periapex.
1>
-f the constriction is destroyed by once&instrumentation
and an apical stop is not developed the chances of long term success
are greatly lessened.
Cepeated instrumentation extending beyond the constriction is
unwarranted. -t causes peri&radicular inflammation and often destroys the
biologic constriction of the root apex.
Although same, perforations of the floor of the nose, maxillary sinus
or mandibular canal as a result of excessive over extension of instruments
can lead to severe post treatment pain, delayed healing and ultimate failure.
Cemento dentinal junction:
-ntentional overextension of instruments post&treatment is warranted
only when damage must be established the periradicular tissues such as in
an acute apical abscess etc.
According to Dutler *1=$;+, the root canal is divided into a long
conical dentinal portion and a short funnel&shaped cemental portion.
The cemental portion is usually in the form of an inverted
cone with its narrowest diameter at or near the cementodentinal
'unctions and its base at the apical foramen.
(owever, occasionally the cementum abuts directly on
the dentin at the apex.
11
At times, the cementum extends for a considerable
distance into the root canal, timing the dentin in an irregular manner.
12
Apical Constriction:
Earrowest portion of the canal coincides with the 7D? location in
relation to apical foramen.
Fsually located >.$&1mm away from A% but this distance can
change with age i.e. deposition of cementum, deposition of 2
nd
dentin G as
in cases of ortho treatment or perio disease.
Shape of canal:
?aid to have a conical dentinal portion and inverted cone cemental
portion.
The apical constriction located at the narrowest opening of the
inverted cone or at the cemento D? bases of inverted cone is at the apical
foramen.
7ementum seen to covered apex of root and sometimes extend into
the root canal a considerable distance. Deposition of cementum varies on
walls.
Clinical sign: -t is believed that the obturation and instrumentation within
the root canal should be limited upto this apical constriction or 7D?. As
this A7 acts like a artificial ledge and provides apical dentin matrix for
condensation on gutta&percha. (owever over instrumentation beyond A7
can lead to4
1!
& 8oss of biologic constriction.
& 3ver extension beyond foramen and
& eri&radicular inflammation.
?ituations are especially likely to occur in periodontally positioned
teeth or in teeth which have been moved orthodontically. -n those
instances, the root canals as well as the apexes may almost become
obliterate by heavy deposition of 2@ cementum.
The extent of cementum deposition on each wall of the root canal
varies, one wall is usually covered with a greater 1uantity of cementum
than the other wall.
3ccasionally, tissue which resembles both dentin and
cementum is seen. The 1uantity of this intermediate tissues varies
among the teeth of different patients.
Eo definite morphological pattern of the cementodentinal
'unction is found consistently.
The thickness of cementum around the apical foramen is
inconsistent and varies greatly.
1#
Significance:
The significance of the cementodentinal 'unction lies in its
implication by a number of investigators *6rove, 1=!>H (all 1=!>H Dult/er
1=$;+ as the precise region to which the root canal should be filled.
Dult/er *1=$$+ claimed that the distance between the 7DI and the
apical foramen averaged >.$><mm in young people and >.<;#mm in older
people, thereby enabling the clinician to measure more precisely the
distance to which the root filling should extend.
(owever, the evidence for this precise location for the terminus of
the root canal filling is lacking.
Accessory canals, Lateral canals:
Cause: Any disturbance to the tooth during formation of the root apex
results in discontinuity of epithelium in (ertwig)s epithelial C?. (ence
failure of dentine formation and cementum deposition at that site leading to
formation of a channel.
These accessory canals usually located in the apical area and are
continuous with the main canal. They end at access foramen.
Incidence:
These accessory canals are usually seen in younger patients. As with
age these channel close with cementum obturation.
1$
7ertain cases accessory canals open at right angles to main chamber
especially at furcation areas of molars or cervical region of roots. These are
termed at lateral canals.
Significance:
1. These canals act as avenues for smear of infection A from infected
pulp to pulp or vice versa i.e. endoperiolesions, microorganisms
breakdown toxic products.
2. -nstruments of these canals during endo treatment is impossible.
(ence if necrotic debris left behind in channels can act as needus for
reinfection. These channels are best delmided chemically with
through filling and reaming.
!. ?tudies show these channels get obliterated with time if pulp vital. -f
non&vital pulp present these channels are filled with granulomatous
tissue.
The aim of endo treatment here would be to remove inflamed tissue
and replace it by healthy connective tissue.
Accessory Canals and Foramina:
The mild trauma to which the tooth is sub'ected during development
of the root apex, may cause disturbance or breakage in the continuity of the
1:
(ertwig)s root sheath more fre1uently, this leading to the formation of
many accessory canals and foramina in the apical third.
These accessory canals branch off from the main root canal and end in
accessory foramina.
They are more common in young patients because they become
obliterated by cementum and dentine as the patient ages.
Accessory canals, which open approximately at right
angles to the main pulp cavity, are termed .lateral canals0 and are
generally found in the furcation area of the posterior teeth.
The accessory and lateral canals are avenues for
interchange of metabolic and breakdown products between the pulp
and periodontal tissues pulps may become inflamed or necrotic
formation the presence of deep periodontal pockets which cause
exposure of the orifices of the canals, thereby permitting the ingress
of toxic products into the pulp.
7onversely, breakdown products of inflammatory pulp
lesions may have an effect on the periodontal tissues via these
canals, causing inflammatory changes.
The number of accessory canals in the root a tooth does not appear to
be a significant factor in success or failure of endodontic therapy in
teeth with vital pulps.
1<
-f they are most endodontic therapy would fail
The apical and accessory foramina provide an opening for
microorganisms and A or toxins to diffuse into the apical periodontal space,
setting up an acute or chronic apical periodontitis. This irritation or
infection may then follow the path of least resistance, which may be in a
coronal direction along the lateral root surface, initiating a marginal
gingivitis or periodontitis.
The inflammatory process may occur in the opposite direction from
the gingiva and along the periodontal ligament space to the apical and
accessory foramina and into the pulp space to establish pulp inflammation
and its se1uelae.
-t would be difficult, if not impossible, by our current techni1ues to
instrument and cleanse the necessary canals, when with thorough reaming
and filing.
?tudies have shown that following endodontics therapy in
teeth with vital pulps, *(ess et al 1=;!+ the lateral and accessory
canals tend to become obliterated by the deposition of cementum
with the passage of time.
-n teeth with totally inflamed A necrotic pulps,
granulomatous tissue is found in the accessory canals prior to
endodontic therapy.
1;
The significance of the involved tissue remaining in the
accessory foramina as a factor of failure of repair after endodontic
therapy has yet been definitely determined.
resumable, following endodontic therapy, the
inflammatory tissue should be resorbed and replaced with
uninflamed connective tissue.
*An accessory canal can also create a periodontic&endodontic
pathway of communication and possible portal of entry into the pulp if the
periodontal tissues lose their integrity+.
-n periodontal disease the development of a periodontal pocket may
expose an accessory canal and thus allow microorganisms or their
metabolic products to gain across to the pulp.
Denticles and Dystrophic inerali!ations:
?elter et alH 1=:: found dystrophic minerali/ations in the
apical pulp tissue of approximately 2$J of anterior teeth.
"inerali/ation within4
& and around the collagen fibres.
& Carely in the myline sheath of the nerves.
"inerali/ation vary in appearance.
& %ine.
1=
& Diffuse.
& %ibrillar variety.
& 8arge denticles.
Koung and old.
"ulp stones #Denticles$:
7ompared of tubular dentin and alveolar minerali/ed
material.
? in G Apical !
rd
G present in 1$J of teeth.
Than 1 stone normally found
Attached 9mbedded
Adherent *only part of it is attached to the dentin+
Clinical Correlations:
Apical !
rd
G difficulty in C7 instrumentation during
reaming and filing.
Detached
-mpacted into the a foramen
Cendering institution difficult.
2>
Apical %esorption:
?hallow resorptions of the dentin in the apical portion by
the root canal are normal cocurrence.
Cesorption of the apex can occur due to several reasons.
-n periodontally involved teeth, the cementum and occasionally
some apical dentin, is completely resorbed from the root apex.
A denuded, scalloped, funnel shaped structure remains.
The root ends may be resorbed during orthodontic tooth
movement of the teeth. The root apex may be obli1uely resorbed or
have a cupped&out appearance.
"ost resorption are repaired by cementum.
-n any event, if apical resorption has taken place, the apical foramen
will be in the center of the root.
-f the root resorption has a .non&eaten appearance0, it is possible
that the tooth, by accident was ripped loose from its ligaments and A or was
replasted.
?ometimes an unexplained lesions in the region strongly suggests a
malignancy.
,hen resorption has enlarged lesion in the region strongly suggest a
malignancy.
21
,hen resorption has enlarged apical portion of the canal, apical
closure techni1ues should be used to ensure a better prognosis for
endodontic therapy *non&surgical+.
Causes of apical resorption:
1. eriodontally involved teeth.
2. 3rthodontic treatment.
!. Accident A trauma.
Almost all resorptions can be repaired by cementum depositions.
Clinical significance:
Due to resorption apical opening enlarged because difficulty in
obtaining seal because apical closure techni1ue to be followed.
1+ The coronal pulp tissues is more felamonous whereas apical tissue
more fibrous. (ence efficiently remove pulp push troach almost past
coronal pulp to apical pulp and from the twist in order to remove
pulp in toto.
2+ This fibrous nature of apical tissue or resists apical progression of
inflmmation and supports blood &&&& that enter the pulp.
22
Apical pulp tissue:
The apical pulp tissue differs structurally from the coronal pulp
tissue.
The apical pulp tissue is more fibrous and contains finer cells than
the coronal pulp tissue.
This fibrous structure appears to act as a barrier against the apical
progression of pulp inflammation.
-t also supports the blood vessels and nerves which enter the pulp.
Clinical correlation in endodotic therapy:
A vital pulp extirpation involves severance of the pulp tissue
somewhere in the apical region of the main canal.
Actually, the plane of severance of the pulp tissue from
the periodontal ligament is not under the complete control of the
operator, especially when a barbed broach is used to extirpate the
pulp.
The seperation can occur anywhere in the root canal or
even beyond the apical foramen, somewhere in the periodontal
ligament.
,hen the latter types of severance occurs, the ensuring
hemorrhage causes a painful pericementitis.
2!
Clinical sign:
1. ,hile extirpating pulp avoid severing pulp at the coronal radicular
pulp function but remove in toto.
2. -f pulp is secured at the apical pulp ply 'unction then leads to painful
periomentitis reaction and hemorrhage.
Instrumentation:
Time spent on the proper preparation of the apical portion greatly
simplifies the subse1uent canal preparation.
The general principles to be adhered to while preparing
the apical third is confine cleaning and shaping procedures
maintainance of the spatial integrity of the foramen and 2+ smooth
shaping of the original course of the canal.
Adherance to this principle prevent violation of the
periradicular tissues. This principle is evident when foramina are
transported *i.e. moved+ during excessive apical instrumentation.
oints to be remembered while enlarging apical4
1. Do not instrument beyond apical constrction because mount
integrity of foramen.
2. %ollow the shape of the canal because this presents damage to
periradicular tissues and transportation of foramena.
2#
Normal transportation can be either:
1. 9xternal
2. -nternal.
9xternal transportation4 takes 2 forms and may occur when
instrumentation is carried out beyond the apical dentin matrix.
3ne result is the ripping of the apical end of the canal resulting 1.
tear drop, 2. elliptical or !. /ipped foramen.
-n its grosser form, external transportation leads to an outright
perforation of the root.
-nternal transportation can also occur when excessively large
instruments are used in the apical third of a curved canal.
9ven though a perforation may not have occurred, there is a definite
loss of the narrowing apical preparation and the spatual relationship of this
preparation to the apical foramen.
9xternal transportation occurs during over instrument beyond the
apical constriction leads to perforations in the apical denture matrix that are
teardrop, elliptical, or /ipped shaped.
-nternal transportation4 due to use of layer instruments at the apical
area leads to of curved canal4
1. 8oss of constriction.
2$
2. 7hange in relation between the apical preparation and apical
foramen.
!. Eo perforation.
6enerally, both types of transportation of the apical foramen can be
prevented by containing cleaning and shaping procedures within the canal
system by4
1. Fsing precurved instruments.
2. by resisting the temptation to excessively enlarge the apical portion
of the canal.
!. by using voluminous irrigation.
#. by preventing a build up of denting shavings during instrumentation
procedure by fre1uent recapitulation.
ethods of preparation:
reparation design has an influence upon the final seal.
?tep back or flaring type of preparation of the apex is
found to be advantageous over the conventional method *Alison et
al 1=<=+.
%lared preparation provides a strong apical dentin matrix
*,eine 1=;2+.
2:
7hances of apical ripping and shafting of foramen are less
with step&back techni1ue *7hristie and eikoff 1=$>+.
"revention of transportation &oth internal and external:
1. Fse precurved instruments.
2. Do not excessively enlarge the apical !
rd
.
!. Fse volumenous irrigation.
#. recapitulation.
Conclusion:
The morphological variations and the technical challenges involved
in the treatment of the apical third seems infinite.
& Cesorptions, weeping apex, immature foramen are some of the areas
which continue to invite fresh viruses from clinicians and
researchers.
& -t has to be remembered while treating the apical third that the
proximity of the apices of certain teeth are in close association with
important structures like maxillary sinus and inferior alveolar nerve.
& -nade1uate attention and improper handling of the apical !
rd
of these
teeth may lead to serious clinical implications.
2<
& ?cience in endodontics has grown to a great height compared to
how it was 2 decades ago.
& 7ases which were ill&understood and found difficult to treat than are
presently managed with case and confidence.
& The drawback which is yet to be tackled is the consumption of
considerable chairside time.
& ,ith the introduction of high technology and advancement of
science in endodontics, the problem is bound to be solved soon.
%eference:
2+ ?amule ?elt/er *2
nd
edition+ *9ndodontology+.
!+ 6rossman *11
th
?olution+ 9ndodontic practice.
#+ arimeswaram *7urrent trends in 9ndodontology+
$+ %.I. (arty *9ndodontics in chemical practice+.
:+ 7ohen *9ndodontics+.
<+ -ngle *9ndodontology+.
2;
A"ICAL '
%D
A(D I)S SI*(IFICA(C+
CONTENTS
1+ -ntroduction
2+ Development of root structures
!+ 7hemical correlation in endodontic therapy
#+ Apical pulp tissue 7linical correlation in endodontic therapy
$+ Apical dentin 7linical correlation in endodontic therapy
:+ Accessory foramina and lateral canal
i+ -mplication of accessory foramina and lateral canal in
endodontic therapy
<+ Denticles and dyostrophic calcifications
;+ 7ementoenamel 'unction G eriodontal involvement
=+ 2
nd
dentin G 7linical significance
1>+ Cesorptions
11+ eriapical region
12+ Ceference
2=