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Endodontic Advances and Evidence-Based Clinical Guidelines
Endodontic Advances and Evidence-Based Clinical
Guidelines
Edited by
Hany M. A. Ahmed
Department of Restorative Dentistry, Faculty of Dentistry, University of
Malaya, Kuala Lumpur, Malaysia
Paul M. H. Dummer
School of Dentistry, College of Biomedical and Life Sciences, Cardiff
University, Cardiff, UK
Companion Website: www.wiley.com/go/ahmed/endodontics

This edition first published 2022
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Library of Congress Cataloging-in-Publication Data

Names: Ahmed, Hany Mohamed Aly, author. | Dummer, Paul Michael
Howell, author.
Title: Endodontic advances and evidence-based clinical guidelines / Hany
Mohamed Aly Ahmed, Paul Michael Howell Dummer.
Description: Hoboken, NJ : John Wiley & Sons, 2022. | Includes
bibliographical references and index.
Identifiers: LCCN 2021045254 (print) | LCCN 2021045255 (ebook) |
ISBN 9781119553885 (paperback) | ISBN 9781119553793 (pdf) |
ISBN 9781119553892 (epub) | ISBN 9781119553939 (obook)
Subjects: LCSH: Endodontics.
Classification: LCC RK351 .A36 2022 (print) | LCC RK351 (ebook) |
DDC 617.6/342--dc23/eng/20211108
LC record available at https://lccn.loc.gov/2021045254
LC ebook record available at https://lccn.loc.gov/2021045255
Cover image: Courtesy of Hany Ahmed, Gabriel Krastl, Jorge Perdigão, Gianluca Plotino,
and Silvio Taschieri
Cover design by Wiley
Set in 9.5/12.5pt STIXTwoText by Integra Software Service Pvt. Ltd, Pondicherry, India
v
Contents
Preface xviii
Acknowledgements xix
Editors’ Biography xx
List of Contributors xxi
About the Companion Website xxv
Part I: Advances in Knowledge 1
1 Tooth, Root, and Canal Anatomy 3

Hany M. A. Ahmed, Ali Keleş, Jorge N. R. Martins, and Paul M. H. Dummer
Summary 3
1.1 Introduction 3
1.2 Different Perspectives in Characterizing Root and Canal Morphology 4
1.2.1 Deficiencies of Current Classification Systems for Root Canal Morphology 5
1.2.2 Introduction to the New Coding System for Root and Canal Morphology 8
1.3 Advances in Apical Canal Morphology 17
1.3.1 Cemento-dentinal Junction (CDJ) 17
1.3.2 Apical Constriction (AC) 18
1.3.3 Major Apical Foramen (MAF) 19
1.3.4 Isthmus 22
1.3.5 Accessory Canals and Apical Deltas 25
1.3.6 Bifid Apex 26
1.3.7 The Importance of Apical Canal Anatomy in Apical Surgery 26
1.4 Root and Canal Morphology in Different Tooth Types 27
1.4.1 Maxillary Anterior Teeth 27
1.4.2 Maxillary First Premolar 28
1.4.3 Maxillary Second Premolar 29
1.4.4 Maxillary First Molar 31
1.4.5 Maxillary Second Molar 31
1.4.6 Mandibular Anterior Teeth 34
1.4.7 Mandibular First Premolar 36
1.4.8 Mandibular Second Premolar 36
1.4.9 Mandibular First Molar 36
1.4.10 Mandibular Second Molar 37
References 39
2 The Bioactive Properties of Dentine and Molecular Advances in Pulp

Regeneration 51
Henry F. Duncan and Paul R. Cooper
Summary 51
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2.1 Introduction 51
2.2 Regenerative Endodontics 53
2.3 The Role of Dentine in Pulpar Repair and Regeneration 53
2.4 Infection, Inflammation, and Stem Cells Interaction in Pulp Regeneration 54
2.4.1 Immune Response 54
2.4.2 Inflammation and Regeneration 56
2.4.3 Opportunities for Clinical Translation 56
2.5 Regenerative Endodontic Procedures (REPs) 57
2.5.1 Cell-Homing 57
2.5.2 Cell-based Therapies 62
2.6 Conclusion 65
References 66
3 Microbial Biofilms in Root Canal Systems 74

Luis E. Chávez de Paz
Summary 74
3.1 Introduction 74
3.2 General Characteristics of Microbial Biofilms 75
3.2.1 How do Bacteria Build Biofilms? 75
3.2.2 Formation of Biofilms in Root Canals 75
3.2.3 Planktonic Versus Biofilm Lifestyles 76
3.2.4 The Biofilm Phenotype 76
3.3 Ecological Factors Affecting Biofilms in Root Canals 77
3.3.1 The Inflammatory and Necrotic Environments 78
3.3.2 The Post-Treatment Environment 78
3.4 Survival of Biofilm Bacteria to Antimicrobials 79
3.5 Biofilm Resistance in Endodontics 80
3.6 Conclusion 81
References 81
4 Pulp, Root Canal, and Periradicular Conditions 85

Paul V. Abbott
Summary 85
4.1 Introduction 85
4.2 What Causes Pulp, Root Canal, and Periradicular Conditions? 86
4.3 The Development and Progression of Pulp and Root Canal Conditions 88
4.4 The Development and Progression of Periradicular Conditions 90
4.5 Classifications of Conditions and/or Diseases 94
4.6 Classification and Description of Pulp and Root Canal Conditions 96
4.7 Classification and Description of Periradicular Conditions 104
4.8 Summary 115
References 115
5 Root Resorption 117

Abdulaziz Bakhsh, Shanon Patel, and Bhavin Bhuva
Summary 117
5.1 Introduction 117
5.2 Histopathology of Root Resorption 119
5.3 Internal Root Resorption 119
5.3.1 Internal Inflammatory Root Resorption 119
5.3.2 Internal Replacement Resorption 120
5.4 External Root Resorption 121
5.4.1 External Inflammatory Resorption 121
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5.4.2 External Replacement Resorption 122

5.4.3 External Surface Resorption 122
5.4.4 External Cervical Resorption 123
References 127
6 Minimally Invasive Endodontics 130

Prasanna Neelakantan, Antonis Chaniotis, and Avijit Banerjee
Summary 130
6.2 Embracing the Concept of Minimally Invasive Endodontics 130
6.2.1 The Need for Patient-focused Approaches 131
6.2.2 Technological Advancements in Endodontics that Has Made Minimally Invasive
Strategies Possible 132
6.2.3 What Does Minimum Intervention Root Canal Treatment Encompass? 133
6.3 Rationale for Minimally Invasive Root Canal Treatment 133
6.3.1 Failure of Root Canal Treatment: Microbial Causes 133
6.3.2 Failure of Root Canal Treatment: Structural Causes 134
6.4 Minimum Intervention in Endodontics: Prevention Is Better than Cure? 134
6.5 Minimally Invasive Management of the Deep Carious Lesion 134
6.6 Minimally Invasive Root Canal Treatment Procedures 136
6.7 Access Cavity Terminology 136
6.8 Minimally Invasive Root Canal Preparation 140
6.8.1 Goals of Root Canal Preparation 140
6.8.2 So, What Happens to These Untouched Walls? 141
6.8.3 Apical Preparation Sizes and Root Canal Preparation Tapers – How Much Is
Enough? 143
6.8.4 Supplementary Irrigation Strategies in Minimally Prepared Root Canals 145
6.8.5 Is It Possible to Clean Root Canals with No Instrumentation at All? 146
6.9 Minimally Invasive Surgical Endodontics 146
6.10 Conclusion 147
References 147
7 Systemic Health and Endodontics 153

Juan J. Segura-Egea and Jenifer Martín-González
Summary 153
7.1 From Focal Infection Theory to Endodontic Medicine 153
7.1.1 The Discredited Focal Infection Theory 154
7.1.2 Endodontic Medicine: Interrelation Between Systemic and Endodontic
Pathosis 154
7.2 Pathways Linking Periapical Inflammatory Lesions to Systemic Health Status 156
7.2.1 The Spread of Endodontic Bacteria to Adjacent Tissues and Organs 156
7.2.2 Local Production of Soluble Regulatory Molecules that May Initiate or Sustain
Inflammatory Events in Remote Tissues and Organs 157
7.2.3 Extrinsic or Intrinsic Pathological Mechanisms Resulting or Contributing to Both
Local and Systemic Inflammation 158
7.3 Endodontic Implications of Systemic Diseases – Systemic Factors Affecting
Periapical Repair 159
7.4 Diabetes and Endodontics 160
7.4.1 Scientific Evidence on the Association Between Diabetes and Endodontics 160
7.4.2 Biological Mechanisms Involved in the Association Between Diabetes and
Endodontics 162
7.4.3 Endodontic Management of Diabetic Patients 164
7.5 Cardiovascular Disease and Endodontics 164
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7.5.1 Scientific Evidence on the Association Between Cardiovascular Diseases and

Endodontics 165
7.5.2 Mechanisms Involved in the Association Between Cardiovascular Diseases and
Endodontics 166
7.5.3 Endodontic Management of Cardiovascular Patients 167
7.6 Relationship Amongst Other Systemic States and Endodontics 168
7.6.1 Smoking Habits 168
7.6.2 Digestive Diseases and Other Systemic Diseases 169
References 170
8 Technology Enhanced Education 178

Nor Nadia Zakaria, Muaiyed M. Buzayan, Donnie Adams, Hany M. A. Ahmed, and
Paul M. H. Dummer
Summary 178
8.2 E-learning in Dentistry 179
8.3 Contemporary E-learning Models 179
8.4 E-learning During the COVID-19 Pandemic 181
8.5 Limitations of E-learning in Dental Education 181
8.6 Advances in Endodontology Education 182
8.6.1 3D Technology for Pre-clinical Training 182
8.6.2 Augmented and Virtual Reality 183
8.7 Digital Dentistry and Clinical Endodontics 185
8.7.1 Guided Endodontics 185
8.7.2 Surgical Endodontics 186
8.8 Conclusion 186
References 186
Part II: Advances in Materials and Technology 191
9 Computed Tomography Imaging Devices and Techniques 193

Marco A. Versiani and Gianluca Gambarini
Summary 193
9.1 Digital Dentistry and Impact on Clinical Training and Education 193
9.1.1 3D Endodontic Rendering 193
9.1.2 3D Endodontic Software 195
9.1.3 Dynamic Navigation Systems (Software and Devices) 200
9.2 Advances in Micro-CT and Nano-CT Technologies and Their Impact on Clinical
Training and Education 208
9.2.1 Fundamentals of Micro-CT and Nano-CT Imaging 209
9.2.2 Micro-CT Versus Nano-CT Technology 211
9.2.3 CT Technology in Dental Education and Training 211
9.2.4 Advances in Micro-CT and Nano-CT Applications 214
9.5 Conclusion 214
References 215
10 Advances in Working Length Determination 218

Mohammad H. Nekoofar
Summary 218
10.2 Morphology of the Root Canal Terminus 219
10.3 Determining the Root Canal Terminus 220
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10.4 An Overview of Basic Electronics 222

10.4.1 Atom Structure 222
10.4.2 Ions and Electrolytes 222
10.4.3 Electrical Charge, Voltage, and Current 223
10.4.4 Resistance 223
10.4.5 Electric Circuits and the Human Body 224
10.4.6 Ohm’s Law 224
10.4.7 Direct Current and Alternating Current 224
10.4.8 Capacitor 225
10.4.9 Impedance and its Measurement 226
10.5 Electrical Features of Tooth Structure 226
10.6 Electronic Root Canal Length Measurement Devices (ERCLMDs) 227
10.6.1 Fundamental Assumption 227
10.6.2 Background 227
10.6.3 Resistance-based ERCLMDs 228
10.6.4 Low-frequency Oscillation ERCLMDs 229
10.6.5 High-frequency Devices (Capacitance-based Devices; ERCLMDs) 229
10.6.6 Capacitance and Resistance ERCLMDs (Look-up Tables) 230
10.6.7 Voltage Gradient ERCLMDs (Difference in Impedance with Three Nodes) 230
10.6.8 Two Frequencies: Impedance and Difference ERCLMDs 231
10.6.9 Two Frequencies: Impedance Ratio (Quotient) ERCLMDs 231
10.6.10 Multifrequency ERCLMDs 233
10.6.11 Root Canal Length Measurement Devices Integrated Into Rotary Endodontic
Motors 233
10.6.12 Effect of ERCLMDs on Cardiac Devices 234
10.6.13 Application of ERCLMDs in the Primary Dentition 234
References 234
11 Advances in Materials and Techniques for Microbial Control 243

Ronald Ordinola-Zapata, Maria T. Arias-Moliz, Prasanna Neelakantan,
Alejandro Perez-Ron, and Joseph T. Crepps
Summary 243
11.2 Biofilms 244
11.3 Sodium Hypochlorite 245
11.4 Detoxification of the Root Canal System by Endodontic Procedures 247
11.5 Inactivation of Root Canal Irrigants 248
11.6 Etidronic Acid and the Continuous Chelation Concept 249
11.7 Cetrimide and Surfactants 251
11.8 Passive Ultrasonic Irrigation 252
11.9 Negative Apical Pressure 252
11.10 Photodynamic Antimicrobial Therapy 253
11.11 Laser-activated Irrigation 255
11.12 Multisonic Technique 256
11.13 Conclusion 257
References 258
12 Nickel-Titanium Metallurgy 268

Ya Shen and Markus Haapasalo
Summary 268
12.1 Introduction and Classification of Current NiTi Alloy Phases 268
12.2 Properties of Each Phase (Austenitic, Martinsitic, R-phase) 270
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12.3 Surface Treatment of NiTi Alloys 272

12.4 Post-machining Heat Treatment of NiTi Alloys 273
12.5 Effects of Irrigants and Sterilisation Procedures on NiTi Alloys 275
12.6 Relevance of Current Studies 275
12.7 Conclusion 277
References 277
13 Rotary and Reciprocating Motions During Canal Preparation 283

Ove A. Peters and Ana Arias
Summary 283
13.1 Goals and Limitations of Engine-driven Root Canal Preparation 283
13.2 Current Instrument Designs, Movements, and Manufacturing Methods 284
13.3 Clinical Recommendations for Rotary and Reciprocating Canal Preparation 287
13.3.1 Preparation for Treatment 287
13.3.2 Early Coronal Modification 288
13.3.3 Working Length and Patency 289
13.3.4 Glide Path Preparation 290
13.3.5 Canal Preparation 291
13.4 Physical Properties of Engine-driven Root Canal Instruments 292
13.4.1 Cutting Efficiency 292
13.4.2 Cyclic Fatigue Resistance 292
13.4.3 Torsional Performance 293
13.5 Surrogate and Clinical Parameters Affecting Outcomes 294
13.5.1 Geometry of Root Canals After Preparation 295
13.5.2 Induction of Dentinal Micro-crack Formation 297
13.5.3 Debris Extrusion and Postoperative Pain 298
13.5.4 Functionality in Retreatment 300
13.6 Clinical Experiences with Rotary and Reciprocating Root Canal Instruments 300
References 301
14 Hydraulic Calcium Silicate-based Endodontic Cements 311

Josette Camilleri
Summary 311
14.2 Material Properties 312
14.2.1 Cement Characteristics 313
14.2.2 Radiopacifier Characteristics 318
14.2.3 Admixtures, Additives, and Vehicles 318
14.3 Classification of Hydraulic Cements 320
14.4 Specific Uses and Material Properties 321
14.4.1 Application on the Coronal Pulp 321
14.4.2 Intraradicular Use 326
14.4.3 Extraradicular Use 330
14.5 Current Challenges and Conclusions 333
References 334
15 Nanomaterials in Endodontics 347

Anil Kishen and Annie Shrestha
Summary 347
15.2 Applications and Challenges 348
15.3 Nanomaterials in Endodontics 348
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15.3.1 Application of nanomaterials for Endodontic Disinfection 350

15.3.2 Nanomaterials in Root Canal Fillings 353
15.3.3 Nanomaterials in Restorative Materials 354
15.3.4 Nanomaterials in Regenerative Endodontic Procedures 356
15.3.5 Nanomaterials as Bioactive Molecule Delivery Systems 357
15.3.6 Nanomaterials in Scaffolds 358
References 359
Part III: Advances in Clinical Management 367
16 Vital Pulp Treatment 369

Henry F. Duncan and Lars Bjørndal
Summary 369
16.2 Caries: Current Thinking and Radiographic Classification 370
16.3 Role of Pulp and Dentine in Repair 371
16.4 What Does Vital Pulp Treatment Encompass? 373
16.5 How Do We Classify and Diagnose Pulpal Disease? 374
16.6 How Do We Treat Pulpal Disease? Techniques to Avoid Pulpal Exposure 375
16.6.1 Indirect Pulp Capping 375
16.6.2 Selective Carious-tissue Removal in One Visit 376
16.6.3 Stepwise Excavation 376
16.6.4 When Should Pulp Exposure Be Avoided? 378
16.6.5 Follow-up 378
16.6.6 Outcome Analysis 378
16.7 How Do We Treat Pulpal Disease? Techniques When the Pulp Is Exposed 379
16.7.1 When Should We Expose the Pulp and How Much Tissue Should We Remove? 379
16.7.2 Direct Pulp Capping 380
16.7.3 Pulpotomy 381
16.7.4 Pulpectomy 383
16.7.5 Assessing Success 383
16.7.6 Future Opportunities and Therapies 384
16.7 Conclusion 385
References 385
17 Detection of Canal Orifices, Negotiation, and Management of Calcified and Curved

Canals 393
Gianluca Plotino and Nicola M. Grande
Summary 393
17.2 Detection of Canal Orifices 394
17.2.1 The Significance of Missed Anatomy on the Prognosis of Root Filled Teeth 394
17.2.2 Anatomical Landmarks for Detection of Root Canals 397
17.2.3 Clinical Detection of Canal Orifices 401
17.2.4 Magnification and Ultrasonics: The Perfect Tools for Detection of Canal
Orifices 407
17.2.5 Radiographic Techniques for Detection of Root Canals 410
17.2.6 Guided Endodontics for Detection of Root Canals 411
17.3 Negotiation of Calcified and Curved Canals 413
17.3.1 Background 413
17.3.2 Negotiation, Glide Path, and Preflaring 414
17.3.3 Clinical Strategies for the Negotiation of Easily Scoutable Canals 415
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17.3.4 Clinical Strategies for the Negotiation of Complex Canals 416

17.4 Shaping of Calcified and Curved Canals 421
17.4.1 Basic Principles 421
17.4.2 The Ideal Instruments for Shaping Calcified and Curved Canals 424
17.5 Conclusion 430
References 430
18 Management of Fractured Instruments 440

Yoshi Terauchi
Summary 440
18.1 Aetiology of Instrument Fracture 440
18.1.1 Factors Affecting Instrument Fracture 440
18.1.2 Incidence of Instrument Fracture 441
18.1.3 Mechanisms for Instrument Fracture 442
18.2 Diagnosis and Treatment Planning of Fractured Instruments 443
18.2.1 Factors Affecting the Success of Instrument Retrieval 443
18.2.2 Diagnostic Examination Using CBCT for Instrument Retrieval 443
18.2.3 Treatment Planning for Instrument Retrieval 446
18.3 Root Canal Preparation Techniques 449
18.3.1 Potential Accidents in Ultrasonic Activation 449
18.3.2 Refinement of the Damaged Ultrasonic Tip 450
18.3.3 Root Canal Preparation Techniques for Visible Instrument Retrieval 451
18.3.4 Root Canal Preparation for Nonvisible Instrument Retrieval 455
18.4 Instrument Retrieval Techniques 458
18.4.1 Type of fluid used in instrument removal attempts 458
18.4.2 Use of Ultrasonic Activation 460
18.4.3 Use of the Loop 462
18.4.4 Use of the XP-endo Shaper 463
18.4.5 Mechanical Techniques Other than Ultrasonics 465
18.4.6 Non-mechanical Techniques 467
18.5 Prognosis 467
References 469
19 Repair of Pulp Chamber and Root Perforations 475

Thomas Clauder
Summary 475
19.2 Occurrence and Diagnosis of Perforations During Root Canal Treatment 476
19.3 Diagnosis of Perforations 478
19.4 Classification of Perforations and Factors Affecting Prognosis 481
19.4.1 Time of Repair 482
19.4.2 Size of Perforation 482
19.4.3 Location of Perforation 483
19.4.4 MTA as a Perforation Repair Material 484
19.4.5 Alternative Materials for Perforation Repair in Specific Indications 485
19.5 Techniques and Considerations to Clinically Repair Perforations 486
19.5.1 Appropriate Material Selection 486
19.5.2 Use of a Matrix 487
19.6 Nonsurgical Management of Perforations 489
19.6.1 Crown, Pulpal Floor, and Furcation Areas 489
19.6.2 Middle One Third of the Root Canal 491
19.6.3 Apical One Third of the Root Canal 498
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19.7 Surgical Management of Perforations 499

19.8 Clinical Outcomes 502
19.9 Conclusion 505
References 505
20 Removal of Root Canal Filling Materials 511

Tina Rödig and Michael Arnold
Summary 511
20.1 Indications for Root Canal Retreatment 511
20.2 Objectives of Root Canal Retreatment Procedures 512
20.3 Removal of Crowns and Posts 513
20.3.1 Indications 513
20.3.2 Post Removal Techniques 514
20.3.3 Complications of Post Placement and Removal 516
20.3.4 Custom Cast Core Posts 516
20.3.5 Ceramic Posts 517
20.3.6 Removal of Fibre Posts (Tooth 26 Case with Video 3) 519
20.3.7 Prognostic Assessment of Post Removal 521
20.4 Methods for Removal of Gutta-percha 524
20.4.1 Hand Instruments 524
20.4.2 Softening of Gutta-percha 526
20.4.3 Engine-driven NiTi Instruments 535
20.4.4 Adjunctive Instruments and Techniques 537
20.5 Removal of Carrier-based Root Canal Filling Materials 539
20.6 Retrieval of Silver Cones 542
20.6.1 Need for Removal 543
20.6.2 Methods of Retrieval 544
20.6.3 Success of Silver Point Removal and Outcome 546
20.7 Removal of Calcium Silicate-based Cements 547
20.8 Removal of Calcium Silicate-based Sealers 548
20.9 Removal of Resorcinol-formaldehyde Resin Paste (Russian Red) 551
References 553
21 Restoration of Root-filled Teeth 565

Sanket Nagarkar, Nicole Theis-Mahon, Ronald Ordinola-Zapata, and Jorge Perdigão
Summary 565
21.2 Examination of Root-filled Teeth Before Selection of a Treatment Approach 566
21.2.1 Ferrule 566
21.2.2 Remaining Coronal Walls 566
21.2.3 Marginal Ridges 566
21.3 Evidence from Clinical Studies Regarding Factors Affecting the Prognosis of Root
filled Teeth 567
21.3.1 Outcome Measures and Clinical Questions Addressed by Clinical Studiess 567
21.4 Decision-making for Restoration of Root filled Teeth 572
21.4.1 Root filled Teeth with Minimal Loss of Coronal Structure 572
21.4.2 Root filled Teeth with Significant Loss of Coronal Structure 572
21.5 Clinical Considerations for the Management of Root filled Teeth Using Posts 573
21.5.1 Relevance of Tooth Anatomy 573
21.5.2 Classification of Posts 575
21.5.3 Effect of Post Space Preparation and Post Placement on the Fracture Resistance of
Root filled Teeth 577
21.5.4 Clinical Steps to Cement a Post 578
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xiv Contents
21.6 Importance of the Final Restoration 582

21.7 Conclusion 583
References 583
22 Classifications and Management of Endodontic-periodontal Lesions 591

Edoardo Foce, Hany M. A. Ahmed, and Ahmed A. R. Hashem
Summary 591
22.1 Communication Pathways Between the Pulp and Periodontal Tissues 591
22.1.1 Endo-perio Lesions: A Terminological Controversy 592
22.1.2 Classifications of Endo-perio Lesions 594
22.1.3 Foce Classification System for Endo-perio Lesions 597
22.1.4 Ahmed Classification System for Endo-perio Lesions 598
22.2 Management and Prognosis of Endo-perio Lesions 601
22.2.1 Crown-down Plaque-induced Periodontal Lesions Without Pulpal Involvement 604
22.2.2 Crown-down Plaque-induced Periodontal Lesions With Pulpal Involvement 606
22.2.3 Down-crown Periodontal Lesions of Endodontic Origin 608
22.2.4 Combined Endo-perio Lesions 610
22.3 Conclusion 610
References 613
23 Management of Coronal Discolouration 617

Hany M. A. Ahmed, Gabriel Krastl, Brigitte Zimmerli, Mohamed Amer, and
Peter Parashos
Summary 617
23.2 Aetiology 617
23.3 Prevention of Coronal Discolouration Related to Endodontic Procedures 620
23.4 Management Guidelines 621
23.4.1 History 621
23.4.2 Evaluation and Preparation 621
23.4.3 Selection of the Appropriate Treatment Approach 621
23.4.4 Types of Intracoronal Bleaching 625
23.5 Bleaching of Teeth with Calcified Pulp Chambers and Root Canals 627
23.6 Prognosis of Intracoronal Bleaching 628
23.6.1 Initial Results of Intracoronal Bleaching 628
23.6.2 Colour Stability 629
23.7 Complications After Intracoronal Bleaching 631
23.8 Other Treatment Options 632
23.8.1 Restoration of Teeth After Bleaching 632
23.9 Tooth Discolouration Following Regenerative Endodontic Procedures 633
23.10 Management of Tooth Discolouration Following Regenerative Endodontic
Procedures 635
References 637
24 Surgical Endodontics 645

Silvio Taschieri and Stefano Corbella
Summary 645
24.2 Historical Perspective 645
24.3 Indications for Surgical Endodontics with Root-end Resection and Treatment
Alternatives 646
24.4 Endodontic Microsurgery (EMS) Technique 647
24.4.1 Diagnosis 647
24.4.2 Anaesthesia 648
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Contents xv
24.4.3 Mucoperiosteal Flap 648

24.4.4 Bone Access 650
24.4.5 Root-end Management 651
24.4.6 Root-end Filling Materials, Types, and Current Advances 653
24.4.7 Management of the Bone Cavity 653
24.5 Prognosis and Outcome Evaluation 654
24.6 Case Difficulty Classification for Surgical Endodontics 663
24.6.1 Patient Level 663
24.6.2 Tooth Level 664
24.7 Other Surgical Endodontics Procedures 665
24.7.1 Incision and Drainage 665
24.7.2 Exploratory Surgery 665
24.7.3 Periradicular Curettage and Biopsy 665
24.7.4 Root Resection 666
24.7.5 Tooth Resection 666
24.7.6 Extraction with Replantation 666
References 666
25 Alternatives to Root Canal Treatment: Tooth Autotransplantation 669

Monty Duggal and Hani Nazzal
Summary 669
25.2 Indications for Autotransplantation 671
25.3 Advantages and Disadvantages of Tooth Autotransplantation 671
25.4 The Role of Interdisciplinary Team Planning 672
25.5 Pretransplantation Bone Management 672
25.6 Case Selection 673
25.6.1 Availability of a Donor Tooth 674
25.6.2 Donor Tooth Assessment 675
25.6.3 Recipient Site Characteristics 675
25.7 Success and Survival of Tooth Autotransplantation 676
25.7.1 Factors Affecting Prognosis of Autotransplanted Teeth 676
25.8 Presurgical Preparations 676
25.9 Tooth Autotransplantation Surgical Technique and Considerations 677
25.10 Socket Assessment 679
25.11 Antibiotic Prophylaxis 681
25.12 Postoperative Instructions 681
25.12.1 Post-transplantation Pulpal and Periodontal Management 681
25.13 Interim Restorative Camouflage 681
25.14 Pulpal Management 682
25.15 Orthodontic Tooth Movement 682
25.16 Definitive Restoration 682
References 682
Part IV: Evidence-based Clinical Guidelines 685
26 Endodontic Diagnosis 687

Pratik Kamalkant Shah and Bun San Chong
Summary 687
26.2 History Taking 688
26.2.1 Presenting Problem 688
26.2.2 Dental History 689
ftoc.indd 15 14-09-2022 18:26:43

xvi Contents
26.2.3 Medical History 689

26.2.4 Antibiotic Cover 690
26.2.5 Social History 690
26.3 Clinical Examination 690
26.3.1 Extraoral assessment 690
26.3.2 Intraoral assessment 690
26.3.3 Routine Tests 692
26.3.4 Special Tests 695
26.3.5 Radiography 704
26.4 Classification of Pulp and Periradicular Diseases 706
26.4.1 American Association of Endodontists Classification System 706
26.4.2 Limitations of the American Association of Endodontists
Classification System 709
26.4.3 Endolight Classification 710
26.5 Referred Pain 711
References 712
27 The Use of Cone-Beam Computed Tomography in Endodontics 719

Shanon Patel, Robert Kelly, and Tiago Pimentel
Summary 719
27.2 Detection of Apical Periodontitis 719
27.3 Root Canal Anatomy 720
27.4 Root Canal Retreatment 721
27.5 Endodontic Surgery 722
27.6 Dental Trauma 723
27.7 Diagnosis and Management of Root Resorption 724
27.8 Vertical Root Fractures 725
27.9 Limitations 726
References 727
28 Endodontic Emergencies and Systemic Antibiotics in Endodontics 734

Juan J. Segura-Egea and Jenifer Martín-González
Summary 734
28.1 Endodontic Emergencies 734
28.1.1 Diagnosis and Treatment Planning in Endodontic Emergencies 735
28.1.2 Emergency Treatment of Symptomatic Reversible Pulpitis 735
28.1.3 Emergency Treatment of Symptomatic Irreversible Pulpitis 736
28.1.4 Emergency Treatment of Acute Periapical Abscess 736
28.1.5 Cracked Tooth 738
28.1.6 Traumatic Injuries of the Teeth 739
28.2 Systemic Antibiotics in Endodontics 739
28.2.1 Antibiotics as Antimicrobial Medicaments in Endodontic Infections 740
28.2.2 Indications for Systemic Antibiotics as Adjuvants in the Treatment of Endodontic
Infections: European Society of Endodontology Position Statement 741
28.2.3 Indications for Antibiotic Prophylaxis in Endodontics: European Society of
Endodontology Position Statement 743
28.2.4 Systemic Antibiotics for the Treatment of Traumatic Injuries of the Teeth 745
28.3 Conclusion 746
References 746
ftoc.indd 16 14-09-2022 18:26:43

Contents xvii
29 Revitalization Procedures 749

Kerstin M. Galler
Summary 749
29.1 Regeneration and Repair Processes in the Dental Pulp 749
29.2 Revitalization – Terminological Aspects 750
29.3 Position Statements of the ESE and AAE 751
29.4 Case Selection, Indications, and Contra-indications 751
29.5 Clinical Procedure 752
29.5.1 Disinfection 752
29.5.2 Provocation of Bleeding 754
29.6 Outcome 755
29.7 Future Perspectives 756
References 756
30 Management of Traumatic Dental Injuries in the Permanent Dentition 761

Gabriel Krastl, Roland Weiger, Andreas Filippi, Kurt A. Ebeleseder, and Kerstin M. Galler
Summary 761
30.1 Introduction and Epidemiological Data 761
30.2 Classification of Traumatic Dental Injuries 762
30.3 Diagnosis of Traumatic Dental Injuries 763
30.4 Enamel Cracks and Crown Fractures 764
30.4.1 Vital Pulp Treatment 765
30.4.2 Materials for Vital Pulp Treatment 766
30.4.3 Success Rates of Vital Pulp Treatment in Traumatised Teeth 767
30.4.4 Reattachment Restoration 767
30.4.5 Direct Resin Composite Restoration 769
30.4.6 Indirect Ceramic Restoration 770
30.5 Crown-root Fractures 770
30.5.1 Adhesive Fragment Reattachment 771
30.5.2 Two-step Direct Composite Restoration 771
30.5.3 Restorative Treatment of the Accessible Regions 772
30.5.4 Surgical Crown Lengthening 772
30.5.5 Extrusion 773
30.6 Splinting of Traumatised Teeth (Root Fractures and Luxation Injuries) 773
30.7 Root Fractures 775
30.8 Luxation Injuries (Concussion, Subluxation, Extrusion, Lateral Luxation) 777
30.9 Luxation Injuries (Intrusion) 779
30.10 Luxation Injuries (Avulsion) 781
30.10.1 Avulsed Teeth with Favourable Storage Conditions 781
30.10.2 Avulsed Teeth with Unfavourable Storage Conditions 782
30.11 Systemic Doxycycline Administration 783
30.12 Tetanus Prophylaxis 783
References 784
Index 794
ftoc.indd 17 14-09-2022 18:26:43

xviii
Preface
Over the last few decades, there has been a substantial increase in the body of knowledge
within the field of endodontology. This has been accompanied by a global increase in the
awareness of clinicians, scientists, and the general public to the benefits of endodontic thera-
pies and the ability of the dental profession to save teeth that in the past may have been
extracted. We are delighted and honoured to contribute to the ever-increasing pool of knowl-
edge in endodontology by presenting the first edition of our new book, Endodontic Advances
and Evidence-Based Clinical Guidelines.
The book is divided into four sections:
Advances in knowledge: This section focuses on the characterisation of root and canal anatomy
using advanced diagnostic techniques, the bioactive properties of dentine and molecular
advances in pulp regeneration, microbial biofilms in the root canal system, pulp and perio-
dontal diseases, root resorption, minimally invasive endodontics, and technology-enhanced
education.
Advances in materials and technology: This section covers advances in computed tomography
imaging devices and techniques, working length determination, advances in materials and
techniques for microbial control, and nickel titanium metallurgy together with recent auto-
mated motions and advances in calcium silicate-based cements.
Advances in clinical management: This section includes current trends for vital pulp therapies,
an update for the detection, negotiation, and management of calcified and curved root canals,
management of fractured instruments, repair of perforation defects, removal of root canal fill-
ing materials, restoration of root filled teeth, management of coronal discolouration, surgical
endodontics, management of endo-perio lesions, and alternatives to root canal treatment.
Evidence-based clinical guidelines: This section includes guidelines for the use of cone-beam
computed tomography in endodontics, endodontic emergencies and use of systemic antibiot-
ics, regenerative endodontic procedures, and management of endodontic complications asso-
ciated with traumatic injuries.
Recent advances in knowledge in the key areas of the specialty and their links to evidence-
based clinical guidelines have allowed the latest scientific evidence to be integrated with treat-
ment guidelines to address the needs of patients. This new and innovative format will enable
undergraduate and postgraduate students, general dental practitioners, specialists, and clini-
cal and non-clinical scientists to update their knowledge and engage with advanced treatment
modalities that will have a significant, positive impact on patient management and treatment
outcomes. Each chapter is accompanied by a large number of high-quality illustrations and
clinical cases that will allow the reader to immediately understand current directions in
research, the underlying concepts and new trends in education, and clinical techniques. The
book is provided in print and eBook formats, and there is a companion website to enable the
reader to access and browse the illustrations in a convenient manner.
Hany M. A. Ahmed
Paul M. H. Dummer
xix
Acknowledgements
The editors would like to thank Wiley for supporting the concept of this new book and over-
seeing its production. Special thanks to Loan Nguyen, Susan Engelken, Erica Judisch, Tanya
McMullin, Christy Michael and Amy Kopperude.
The editors gratefully acknowledge the contributing authors for sharing their valuable
knowledge and experience.
We are also grateful to Muhammad Fairos Bin Jenal, Artist, Faculty of Dentistry, University
of Malaya, for the drawings included in several chapters.
We would like to acknowledge and thank our families for their encouragement and con-
tinuous support along the way!
xx
Editors’ Biography
Dr. Hany M. A. Ahmed, BDS, HDD, PhD, FICD, MDTFEd (RCSEd), FPFA, FADI
Dr. Ahmed graduated with a BDS (2002) from the Faculty of Dentistry, Ain Shams University,
Egypt. In 2006, he obtained a Higher Dental Diploma degree in endodontics, followed by a PhD
from the School of Dental Sciences, Universiti Sains Malaysia. He was awarded for his research
including the IADR (SE Asian division) for the best laboratory research, in addition to the best
publication award (2020), with a research group in Turkey, from the Journal of Endodontics.
Dr. Ahmed has had work published in over 100 publications. In 2012, he introduced a new
classification for endo-perio lesions, and in 2017, with experts in the field, he introduced a
new system for classifying root and canal morphology, accessory canals, and dental anoma-
lies, in addition to the PROUD-2020 reporting guidelines. He is an international consultant for
research projects in several countries, and a key opinion leader for dental companies.
Currently, Dr. Ahmed is a senior lecturer in endodontics at the Faculty of Dentistry,
University of Malaya (UM). He leads a number of grants related to root canal anatomy and
endodontic bio-materials. In 2019, he was awarded the excellent service certificate from UM.
Dr. Ahmed is also a registered specialist in endodontics with the Egyptian Dental Syndicate
(2012-up to date).
Recently, Dr. Ahmed was awarded membership from the Faculty of Dental Trainers, Royal
College of Surgeons (Edinburgh). He is a fellow of the International College of Dentists,
Academy of Dentistry International, and Pierre Fauchard Academy.
Dr. Ahmed is a scientific reviewer and editorial board member for several journals. He is
also the Deputy Editor-in-Chief of the European Endodontic Journal.
Emeritus Professor Paul M. H. Dummer BDS, MScD, PhD, DDSc, FDS (RCSEd)
Professor Dummer graduated from the School of Dentistry, Welsh National School of Medicine,
UK in 1973 with a bachelor’s degree in dental surgery and completed his MScD in 1980 and PhD
in 1987 by research. He was awarded a senior doctorate in dental science (DDSc) in 2002 on the
basis of his research record in endodontology. He has published over 300 original scientific
articles in high-impact peer-reviewed journals and written several chapters in textbooks.
Professor Dummer was a professor of restorative dentistry at the School of Dentistry, Cardiff
University, UK from 1995 to 2017 and vice dean between 2005 and 2011. He was dean for
Education and Students in the College of Biomedical and Life Sciences, Cardiff University
from 2011 to 2017, with overall responsibility for the quality of education in seven schools,
including medicine, dentistry, pharmacy, nursing, optometry, psychology, and biosciences. He
was director of the 3-year master’s programme in clinical dentistry (endodontology) at Cardiff
from 2010 to 2017. He retired in 2017 and is now an emeritus professor at Cardiff University.
Paul Dummer was a clinical consultant in restorative dentistry with the Cardiff & Vale
University Health Board (2000–2017) and a registered specialist in restorative dentistry and
endodontics with the UK General Dental Council (2000–2017).
Paul Dummer was Editor-in-Chief of the International Endodontic Journal (1999–2021) and
the president of the European Society of Endodontology (2020–2021), having been interim
chief executive officer (2017–2019) and secretary (2009–2017).
xxi
List of Contributors
Paul V. Abbott Umm Al-Qura University

UWA Dental School Faculty of Dentistry
The University of Western Australia Makkah, Saudi Arabia
Perth, Australia
Avijit Banerjee
Donnie Adams Conservative and MI Dentistry
Department of Educational Management Faculty of Dentistry, Oral and
Planning & Policy Craniofacial Sciences
Faculty of Education King’s College London
University of Malaya London, United Kingdom
Kuala Lumpur, Malaysia
Bhavin Bhuva
Hany M. A. Ahmed Department of Endodontics
Department of Restorative Dentistry Faculty of Dentistry, Oral &
Faculty of Dentistry Craniofacial Sciences
University of Malaya King’s College London
Kuala Lumpur, Malaysia London, United Kingdom
Mohamed Amer Lars Bjørndal

Melbourne Dental School Cariology and Endodontics
The University of Melbourne Faculty of Health and
Victoria, Australia Medical Sciences
Department of Odontology
Ana Arias University of Copenhagen
Department of Conservative and Copenhagen, Denmark
Prosthetic Dentistry
School of Dentistry Muaiyed Mahmoud Ali Buzayan
Complutense University Department of Restorative Dentistry
Madrid, Spain Faculty of Dentistry
University of Malaya
Maria T. Arias-Moliz
Department of Microbiology
School of Dentistry
Josette Camilleri
University of Granada
School of Dentistry
Granada, Spain
Institute of Clinical Sciences
College of Medical and Dental Sciences
Michael Arnold
University of Birmingham
Private practice limited to Endodontics
Birmingham, United Kingdom
Dresden, Germany
Antonis Chaniotis
Abdulaziz Bakhsh
Private practice limited to Microscopic
Restorative Department
Endodontics
Endodontic Division
xxii List of Contributors
National and Kapodistrean University Dublin Dental University Hospital

of Athens (NKUA) Trinity College Dublin
Dental School, Department of Endodontics Dublin 2, Ireland
Athens, Greece
Kurt A. Ebeleseder
Luis E. Chávez de Paz University Clinic of Dental Medicine
Department of Endodontics and Oral Health
Karolinska Institute Medical University Graz
Stockholm, Sweden Graz, Austria
Bun San Chong Andreas Filippi

Institute of Dentistry Department of Oral Surgery
Faculty of Medicine & Dentistry Center of Dental Traumatology
Queen Mary University of London University Center for Dental
London, United Kingdom Medicine UZB
University of Basel
Thomas Clauder Basel, Switzerland
and Periodontics Edoardo Foce
Hamburg, Germany Private practice
La Spezia, Italy
Paul R. Cooper
Faculty of Dentistry Kerstin M. Galler
University of Otago Department of Conservative Dentistry and
Dunedin, New Zealand Periodontology
University Hospital Erlangen
Stefano Corbella Erlangen, Germany
Deptartment of Biomedical
Surgical and Dental Sciences - Università Giamluca Gambarini
degli Studi di Milano Dipartimento di Scienze
Milan, Italy Odontostomatologiche
Corso di Laurea in Odontoiatria e
IRCCS Ospedale Galeazzi - Sant’Ambrogio
Protesi Dentaria
Milan, Italy
Università degli studi di Roma
La Sapienza
Joseph T. Crepps
Roma, Italy
Division of Endodontics
University of Minnesota
Nicola M. Grande
School of Dentistry, Minneapolis
Department of Operative Dentistry
Minnesota, United States of America
and Endodontics
School of Dentistry
Monty Duggal
Catholic University of Sacred
College of Dental Medicine
Heart (UCSC)
Qatar University
Rome, Italy
Doha, Qatar
Markus Haapasalo
Paul M. H. Dummer
School of Dentistry
Faculty of Dentistry
College of Biomedical and Life Sciences
University of British Columbia
Cardiff University
Vancouver, Canada
Cardiff, United Kingdom
Ahmed A. R. Hashem
Henry F. Duncan
Department of Endodontics
Division of Restorative Dentistry &
Periodontology
List of Contributors xxiii
Ain Shams University Mohammad H. Nekoofar

Cairo, Egypt Department of Endodontics
School of Dentistry
Ali Keleş Tehran University of Medical
Department of Endodontics Science (TUMS)
Faculty of Dentistry Tehran, Iran
Ondokuz Mayis University
Samsun, Turkey Ronald Ordinola-Zapata
Robert Kelly University of Minnesota
Private practice School of Dentistry
Bristol, United Kingdom Minneapolis, Minnesota
United States of America
Anil Kishen
Faculty of Dentistry Peter Parashos
University of Toronto Melbourne Dental School
Toronto, Canada The University of Melbourne
Victoria, Australia
Gabriel Krastl
Department of Conservative Dentistry Shanon Patel
and Periodontology Guy’s, King’s, St Thomas’ Dental Institute
Center of Dental Traumatology King’s College London, Guy’s Tower
University Hospital of Würzburg London, United Kingdom
Würzburg, Germany
Alejandro Perez-Ron
Jenifer Martín-González Department of Dental Research
Department of Stomatology Faculty of Dentistry
School of Dentistry Iguaçu University (UNIG)
University of Sevilla Nova Iguaçu
Sevilla, Spain Rio de Janeiro, Brazil
Endochat Research Group Rio de Janeiro
Jorge N. R. Martins
Rio de Janeiro, Brazil
School of Dentistry
University of Lisbon Department of Endodontics
Lisbon, Portugal University Rey Juan Carlos
Madrid, Spain
Sanket Nagarkar
Private practice at Park Dental Jorge Perdigao
Minneapolis, MN USA Department of Restorative Sciences
University of Minnesota University of Minnesota
Minneapolis, MN School of Dentistry
United States of America Minneapolis, Minnesota
United States of America
Hani Nazzal
College of Dental Medicine Ove A. Peters
Qatar University School of Dentistry
Doha, Qatar The University of Queensland
Brisbane, Australia
Prasanna Neelakantan
Division of Restorative Tiago Pimentel
Dental Sciences Faculty of Dentistry, Oral &
Faculty of Dentistry Craniofacial Sciences
The university of Hong Kong King’s College London
Hong Kong London, United Kingdom
xxiv List of Contributors
Gianluca Plotino Faculty of Dentistry

Private Practice Bahçeşehir University
Rome, Italy İstanbul, Turkey
Henry M. Goldman School of
Tina Rödig
Dental Medicine
Department of Preventive Dentistry
Boston University
Periodontology and Cariology
Boston, United States of America
University Medical Center Göttingen
Göttingen, Germany Tokyo Medical and Dental University
Tokyo, Japan
Juan J. Segura-Egea
Department of Endodontics
Tokyo, Japan
School of Dentistry
University of Sevilla
Nicole Theis-Mahon
Sevilla, Spain
Health Sciences Library
University of Minnesota
Pratik Kamalkant Shah
Minneapolis, United States of America
Institute of Dentistry
Faculty of Medicine & Dentistry
Marco A. Versiani
Queen Mary University of London
Dental Specialty Center
London, United Kingdom
Brazilian Military Police
Belo Horizonte, Brazil
Ya Shen
Roland Weiger
Department of Periodontology,
University of British Columbia
Endodontology and Cariology
Vancouver, Canada
Center of Dental Traumatology
University Center for Dental Medicine UZB
Annie Shrestha
University of Basel
Basel, Switzerland
University of Toronto
Toronto, Canada
Nor Nadia Zakaria
Department of Department of Paediatric
Silvio Taschieri
Dentistry & Orthodontics
Deptartment of Biomedical, Surgical
and Dental Sciences -
University of Malaya
Università degli Studi di Milano
Milan, Italy
IRCCS Ospedale Galeazzi - Sant’Ambrogio Brigitte Zimmerli
Milan, Italy Zahnarztpraxis Braun & Zimmerli
(private practice)
Yoshi Terauchi Burgdorf
Department of Endodontics Switzerland
xxv
About the Companion Website
This book is accompanied by a companion website which includes resources created

by the authors that you will find helpful.
http://www.wiley.com/go/ahmed/endodontics
The website includes the following material:

● Figures
● Videos
● Additional resources
1
Part I
Advances in Knowledge
3
Tooth, Root, and Canal Anatomy

Hany M. A. Ahmed, Ali Keleş, Jorge N. R. Martins, and Paul M. H. Dummer
Summary
Knowledge of root and canal morphology is a prerequisite for successful endodontic treatment.
The external and internal morphological features of roots are variable and complex. Current
advancements in non-destructive digital image systems, such as cone-beam computed tomogra-
phy (CBCT) and micro-computed tomography (micro-CT), allow detailed qualitative and quanti-
tative analyses of root and canal morphology. This growing body of knowledge has paved the way
for revising several historical concepts and introducing new perspectives for more accurate
descriptions of root and canal morphology in teaching, research, and clinical practice. This chapter
aims to provide an update on the application of a new system for classifying root and canal mor-
phology, accessory canals, and anomalies, to discuss anatomy of the root apex and apical foramen,
and to present the growing body of knowledge on root and canal morphology in all tooth types.
1.1 Introduction
Effective endodontic treatment requires a thorough knowledge and understanding of root

and canal anatomy [1]. For decades, this topic has been the subject of many experimental
and clinical reports using a wide variety of techniques such as injection of vulcanized rub-
ber following by decalcification, staining and clearing, 2D radiographic imaging, scanning
electron microscopy, cone beam computed tomography (CBCT) and micro-computed
tomography (micro-CT) [2–7] (Figures 1.1 and 1.2), and it is obvious that root and canal
morphology varies greatly between different tooth types and populations, within popula-
tions, and even within the same individual [1, 7–9]. Recently, new perspectives on the char-
acterisation of root canal configurations, accessory canals, and anomalies [10–13] have
emerged, in addition to growing knowledge related to the fine details of the apical canal
morphology [14, 15], and anatomical variations amongst different population groups [6,
16–18]. In this chapter, the application of a new coding system for classifying root and canal
anatomy is described, and recent advances on the morphology of the root apex and apical
foramen are discussed. In addition, this chapter presents updated information on root and
canal anatomy evidenced in prevalence studies using CBCT technology.
Endodontic Advances and Evidence-Based Clinical Guidelines, First Edition. Edited by Hany M. A. Ahmed
and Paul M. H. Dummer.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/ahmed/endodontics
4 Advances in Knowledge
Figure 1.1 Common methods for the study of root and canal morphology in extracted teeth. (a) Staining and clearing. (b) 2D radiographic
imaging with different views. (c) Stereomicroscopy. (d) Scanning electron microscopy. (e) Cone beam computed tomography.
(f) Micro-computed tomography.
1.2 Different Perspectives in Characterizing Root and Canal

Morphology
Classifications play a central role in science, where they are used not only as a way to organise
knowledge but also as a powerful tool for accurately defining characteristic features of a given
subject [19]. Data generated from the classical work of Hess and Zurcher [2] to the more
recent studies demonstrate that the ever-expanding knowledge on this subject required the
creation of a classification system for defining root canal configurations. The Vertucci classifi-
cation [3] is the most commonly used system for categorising canal morphology; however,
several reports identified considerable deficiencies in this system [10, 13]. In this section,
these deficiencies are discussed and a new coding system for classifying root canal morphol-
ogy, accessory canals, and anomalies is described.
Tooth, Root, and Canal Anatomy 5
Figure 1.2 Common methods for the study of the root and canal morphology in clinical practice. (a) 2D radiographic imaging. (b, c) Clinical
identification using magnification, exploration, and troughing. (d) Identification using hand files. (e, f) Cone beam computed tomography in
mandibular (e) and maxillary (f) teeth.
1.2.1 Deficiencies of Current Classification Systems for Root Canal

Morphology
Using sectioning and 2D radiographic methods, Weine et al. [4, 20] categorised root canal con-
figurations within a single root into four types depending on the pattern of division of the main
root canal along its course from the pulp chamber to the root apex (Figure 1.3a). Later, Vertucci
et al. [21] developed a classification system based on the evaluation of 200 cleared maxillary
second premolars, and identified a total of eight configurations (Figure 1.3b). Investigators
[22–25] added 15 more supplemental canal configurations to Vertucci’s classification (Figure
1.3c) with other non-classifiable configuration types being recently introduced [26].
The systems proposed by Vertucci et al. [21] (and its supplemental categories) have been the
most commonly used and have been beneficial when categorising many canal configurations.
However, considerable deficiencies exist because of the following:
1.2.1.1 No Consideration of the Number of Roots in Anterior and Premolar Teeth

In Vertucci’s classification, there is no description of the number of roots in anterior and pre-
molar teeth. Therefore, it is not possible to differentiate between Vertucci type IV (2 separate
root canals) in a single- or a double-rooted tooth (Figure 1.4a, b). Similarly, it is not possible to
define Vertucci type V (1-2) that can exist in a single- or a double-rooted tooth (Figure 1.4c, d).
Clearly, in terms of the clinical management of teeth undergoing root canal treatment and
endodontic surgery, it is critical to define the number of roots and not just canals, as this will
have implications in terms of access cavity preparation as well as visualisation of canal ori-
fices, instrumentation, post preparation, and root-end resection, if indicated [8]. In addition,
all three-canalled maxillary (or mandibular) premolars (or anteriors) are coded as Vertucci
type VIII with no consideration given to the number of roots or level of the canal bifurcations
(Figure 1.4e, f).
Figure 1.3 Common classifications for root canal configurations. (a) Weine classification from left to right [Type I (1), II (2-1), III (2), IV (1-2)];
(b) Vertucci classification from left to right [Type I (1), II (2-1), III (1-2-1), IV (2), V (1-2), VI (2-1-2), VII (1-2-1-2), VIII (3)]; (c) Supplemental
configurations from Vertucci classification from left to right [Type IX (1-3), X (1-2-3-2), XI (1-2-3-4), XII (2-3-1), XIII (1-2-1-3), XIV (4-2), XV
(3-2), XVI (2-3), XVII (1-3-1), XVIII (3-1), IXX (2-1-2-1), XX (4), XXI (4-1), XXII (5-4), XXIII (3-4)].
To overcome this deficiency in Vertucci’s classification, the number of roots has been described
in various case reports and studies alongside the Vertucci classification but with no details on
their location, and this is also considered insufficient. For instance, double-rooted anterior teeth
can exist in two forms (mesial and distal, or buccal and palatal/lingual) [27]. Three-rooted max-
illary premolars can have two forms (i.e. two buccal roots and one palatal root or one buccal root
and two palatal roots) [8, 10, 28]. Therefore, it is not only important to present the number of
roots of a given tooth but also to describe the location of these roots as this detailed description
of the roots has clinical implications at different phases of treatment.
1.2.1.2 Absence of Clear Definitions of Root Canal Components

In Vertucci’s classification, the root canal orifice is defined as ‘a root canal begins as a funnel-
shaped canal orifice generally present at or slightly apical to the cervical line,’ [1], with no
description of this ‘slight apical’ position. One possible reason is that the Vertucci classifica-
tion was based on staining and clearing methods in which teeth were subject to decalcifica-
tion, staining, and clearing; such procedures significantly deteriorate the normal anatomical
features of the tooth, including the cemento-enamel junction (CEJ), thus making its identifi-
cation, in some samples, rather challenging. Notably, in multi-rooted teeth, the location of the
pulp chamber floor may not coincide with the CEJ [1, 29].
Another potential confusion exists over how to define inter-canal communications, which can
be classified as an integral part of the root canal configuration with an impact on its classification,
or simply as a minor feature with no impact on its anatomical classification (Figure 1.5). An inter-
canal communication (transverse canal anastomosis, canal isthmus) has been defined by the
American Association of Endodontists (AAE) [30] as a thin communication between two or more
Figure 1.4 Application of the Vertucci classification in teeth with different root canal configuration types. Teeth with 2 separate root canals
in (a) single-rooted, and (b) double-rooted maxillary premolars are classified as Type IV. Teeth with root canal configuration (1-2) in
(c) single-rooted, and (d) double-rooted mandibular premolars are classified as Type V. Vertucci Type VIII can be presented in (e) double-
rooted and (f) three-rooted maxillary premolars with three root canals.
Figure 1.5 Micro-CT reconstruction of a

right mandibular first premolar classified
using the Vertucci classification with and
without considering the inter-canal
communications. Reproduced from Ahmed
et al. [218] with permission.
canals in the same root or between vascular elements in tissues. Classifying the root canals using
the Vertucci classification could vary and become more complicated if inter-canal communica-
tions are considered as a part of the main canal configuration (Figure 1.5). Since the criteria for
defining inter-canal communications were not mentioned [3] (Figure 1.5), the confusion is more
obvious when micro-CT studies continue to report many canal configurations as ‘non-classifiable’
when using the Vertucci classification [31, 32]. This may well be the case for some ‘complicated’
canal configurations but is misleading for many other types because such studies have always
included transverse canal anastomosis as a part of the main canal configuration [31, 32]. At the
same time, several CBCT studies either have not considered transverse canals as a part of the root
canal configuration or did not mention the criteria of transverse canals if they are not meant to be
considered [6, 33–35]. As a consequence of this variation in interpretation, comparison amongst
studies creates conflicts not only because of the different methods used to prepare the specimens
but also because the same classification system is being used in a different manner.
The identification of a transverse canal anastomosis separately from the canal configuration
is a concern because they have clinical implications during chemo-mechanical instrumenta-
tion, canal filling, and root-end cavity preparation and filling [36–38]. In addition, transverse
canal anastomosis may communicate with the external root surface and be a pathway for
microorganisms and their associated toxins into the lateral periodontal and periapical tissues,
thus affecting clinical outcomes [39].
In addition, there is confusion with regards to apical canal bifurcations – when it is a part of
the configuration and when it is considered as an accessory canal. Similar confusion exists for
apical root bifurcations whether a tooth with a bifid/small double root apex is considered as a
single- or double-rooted tooth, which is discussed later in this chapter.
1.2.1.3 Non-classifiable Root Canal Configurations

Recent reports on the identification of external and internal anatomical canal variations using
advanced 3D imaging technology have revealed that the morphological characteristics of the
root canal system are highly complex, and many canal configurations have been described as
‘non-classifiable’ [31, 40–42]. It is obvious that the use of Roman numerals for describing the
wide variations in the types of root canal configuration is impractical.
1.2.2 Introduction to the New Coding System for Root and Canal Morphology
Recently, an alternative coding system for classifying root and canal morphology was pro-
posed, which provides detailed information on tooth notation, number of roots and root canal
configuration [10]. The new system aims to provide a simple, accurate, and practical way for
students/trainees, clinicians, and researchers to classify root and root canal configurations
identified using any diagnostic method regardless of their accuracy and reliability.
1.2.2.1 Terminology
– Root canal system:

The space within the tooth that contains pulp tissue. The root canal system is divided into two
portions: the pulp chamber and the root canals.
– Pulp chamber:
The portion of the pulp space within (or extending to just below) the anatomic crown of the
tooth. In single-rooted teeth and double/multi-rooted teeth with middle or apical root bifurca-
tions with a single canal coronally, it extends to the most apical portion of the cervical margin
of the crown, and in double/multi-rooted teeth with coronal root and/or canal bifurcations
(no single canal coronally), it extends to the floor of the pulp chamber located in the coronal
third of the root. A chamber (accessory) canal is a small canal leaving the pulp chamber that
(usually) communicates with the external surface of the root (including the furcation). It can
be of any type (patent, blind, or loop).
– Root canal orifice:

The opening of the canal system at the base of the pulp chamber where the root canal begins.
Generally, it is located at or just apical to the cervical line.
– Root canal configuration:
The course of the root canal system that begins at the orifice and ends at the canal terminus
(minor apical diameter).
– Major apical foramen:
The exit of the root canal onto the external root surface, which is normally located within
3 mm of the root apex.
– Minor apical foramen/apical constriction:
The apical part of the root canal with the narrowest diameter which is generally 0.5–1.5 mm
from the major apical foramen. It is the reference point often used as the apical termination of
canal instrumentation and filling procedures.
– Accessory canal:
A small canal leaving the root canal that (usually) communicates with the external surface
of the root or furcation. Hence, it can be located anywhere along the length of the root (coro-
nal, middle, or apical third) and can be any type (patent, blind, loop) (Figure 1.6). It also
includes what have been in the past termed lateral canals. Apical delta (or apical ramifica-
tions) is the region at or near the root apex where the main canal divides into multiple acces-
sory canals (more than two).
1.2.2.2 Classification
The new classification includes codes for three separate components: the tooth number, the
number of roots, and the root canal configuration.
1.2.2.2.1 Tooth Number

The tooth number (TN) can be written using any numbering system (e.g. universal numbering
system, Palmer notation numbering system, FDI World Dental Federation numbering system).
If the tooth cannot be identified using one of the numbering systems (i.e. extracted teeth), then
a suitable abbreviation can be used, for example UCI for upper (maxillary) central incisor (UCI).
1.2.2.2.2 Number of Roots

The number of roots (R) is added as a superscript before the tooth number (RTN). For instance,
1
TN means that the tooth has one root. Any division of a root, whether in the coronal, middle,
or apical third, will be coded as two or more roots. Accordingly, a bifurcation is represented as
2
TN, and trifurcation is represented as 3TN and so on.
1.2.2.2.3 Root Canal Configuration

The type of root canal configuration (RCC) in each root is identified as a superscript number(s)
after the tooth number and will define the continuous course of the root canal system starting
Figure 1.6 Types of accessory canals – Patent, blind, loop and delta.
from the orifice(s) (O), through the canal (C), and to the foramen (foramina) (F). The new system
for root and canal morphology defines the root canal configuration with a start (root canal ori-
fice) passing through the canal and ends at the apical foramen. Figures 1.7–1.9 show the applica-
tion of the new system on different teeth with a range of root canal configurations. On some
occasions, the root bifurcation in double/multi-rooted teeth is located in the middle or apical
third, in which a common canal is present coronally that starts from the level of CEJ, similar to
single-rooted teeth. This common canal is written as a superscript before describing the canal
configuration for each of the roots (Figure 1.10). Recently, the new coding system has been
refined for application in the primary dentition [43].
Figure 1.7 Application of the

new coding system in single-
rooted teeth.
Figure 1.8 Application of the new

coding system in double-rooted
teeth.

new coding system in three-
rooted teeth.

new coding system to describe
the common canal below the
pulp chamber.
1.2.2.2.4 Location of Accessory Canals

The new coding system can also be used to classify accessory canals with canal configurations
in a single code. The length of the root is divided into thirds (T): the coronal third (C), which
starts from an imaginary line from the most apical portion of the pulp chamber, middle third
(M), and apical third (A) ending at the canal terminus. Each third is identified as a superscript
within parenthesis after the root canal configuration. In some instances, the accessory canal
may not end in a foramen and in that situation, configuration code (1‐0) will describe a blind
accessory, and code (2‐1‐0) will describe a looped accessory canal. Figures 1.11 and 1.12 show
the application of the new coding system for accessory canals.
1.2.2.2.5 Presence of Dental Anomalies

The new coding system can be adapted for root anomalies by including codes for anomalies
and their subtypes (if present). The abbreviation of the anomaly (A) is added between brack-
ets. For example,
● (DE) refers to dens evaginatus affecting a given tooth. If more than one of the same anomaly
exists in one tooth, then the number is written on the left of the anomaly. Thus, (2A)
describes a tooth with two of the same anomaly; thus, (2DE) describes a tooth with two dens
evaginatus.

different locations and types of
accessory canals. (A1) refers to one
accessory canal in the apical third.
(M1) refers to one accessory canal
in the middle third. (C1) refers to
one accessory canal in the coronal
third. (D) refers to apical delta.
(M1, D) refers to the presence of
one accessory canal in the middle
third, and an apical delta.

accessory canals in a double
rooted maxillary premolar.
Reproduced from Ahmed et al.
[218] with permission. This code
refers to the presence of a
double-rooted maxillary right
first premolar tooth (14) in which
the buccal root (B) has 1-2 canal
configuration and one accessory
canal in the coronal third (C1),
and the palatal root (P) has 1
canal configuration and two
accessory canals in the apical
third [one patent (1) and one
blind (1-0)].
● When the tooth has two or more different developmental anomalies, a comma (,) should be
added between the initial letters of each anomaly (A1, A2). Thus, (DI, RD) describes a tooth
with both a dens invaginatus (DI) and a root dilaceration (RD).
● A slash (/) should be used in fused teeth, for example, fusion of one tooth to a supernumer-
ary tooth, or fused roots in double-rooted teeth such as C-shaped canals occurring in fused
double-rooted mandibular molars [44]. Two slashes (//) should be used in fused teeth or
roots with intercommunications in the root canal and/or pulp chamber.
● The subtype of each classified anomaly (if present) should be written as a superscript after
the abbreviation of the anomaly. Thus, (DII) describes a tooth with a dens invaginatus type
I [45, 46]. In some instances, it may be impossible to define a subtype of the anomaly during
an examination (such as during conventional radiographic examination), or when it is not
relevant within a specific clinical or experimental report; in such cases, writing the abbre-
viation of the anomaly without a subtype would be sufficient.
Figures 1.13 and 1.14 show the application of the new coding system in teeth with dental
anomalies.

new system to describe C-shaped
canals. Reproduced from Ahmed
et al. [218] with permission. This
code refers to a mandibular right
second tooth (47) with fused
mesial (M) and distal (D) roots
and C-shaped canals (CSC, type 1)
with a canal configuration 1-2-1.
Double slashes indicate that both
fused roots also share the root
canal configuration.

new system to describe a
mandibular molar with radix
entomolaris. The observer can use
the new system to describe only
the root canal configuration or
root canal configuration and
accessory canals, or root canal
configuration, accessory canals
and anomalies.
1.2.2.3 Applications of the New System in Teaching

To deliver the information required to allow dental students to learn and acquire knowledge for
clinical practice is a significant responsibility [47]. Inadequate understanding and inability to
systematically address normal and unusual anatomical variations of roots and root canals in a
given tooth are the main causes of failure of primary root canal treatments as a consequence of
persistent infection within the root canal space [48]. Root and canal morphology are integral
components of the endodontic curriculum, and it is the initial educational step to develop under-
standing in tooth anatomy before practicing endodontic treatment and surgical procedures.
A recent national survey study compared feedback from undergraduate Malaysian den-
tal students on both the Vertucci and Ahmed et al. systems [49]. The results revealed that
90% or more of students believed that the new system for classifying root and canal mor-
phology was more accurate and more practical compared to the Vertucci classification and
its supplemental configurations. More than 95% of students believed that the new system
aided their understanding of root and canal morphology, and they would recommend its
inclusion in preclinical and clinical courses (Figure 1.15). Similar results were observed
amongst postgraduate dental students [49]. This is also consistent with results of another
online survey undertaken amongst general dental practitioners (GDPs) and endodontists
in Perú [50].
This favourable feedback is probably attributed to the fact that the new classification is an
‘open system’ that can describe the number of roots accurately and does not have certain types
for categorizing the root canal morphology (no need to memorize certain categories). It is
worth noting that the survey only focused on root canal configurations; however, participants
in the survey undertaken in Malaysia raised comments on the possibilities of using the new
system to classify accessory canals and anomalies [49]. Even though these anatomical land-
marks were not included in that survey, such reflections demonstrate the ability of students to
apply factual knowledge to understand, analyse, evaluate, and even create or add to the origi-
nal product/system [51]. Similar survey studies on accessory canals and anomalies are needed,
which have important clinical implications at the undergraduate and postgraduate level.
Indeed, results of such surveys should not undermine the value of previous classification sys-
tems; students, GDPs, and endodontists still have to be aware of the advantages and limitations
of Vertucci’s classification.
The canal coding system has recently been used with other teaching modules such as virtual
reality [52].
Figure 1.15 A bar chart showing results of two survey studies undertaken in Malaysia [49] and Peru [50].
1.2.2.4 Applications of the New System in Research

The new coding system has been used in a number of clinical and experimental CBCT studies
on Egyptian [53], Chilean [54], Polish [55], Malaysian [56, 57] and South African [58] popula-
tions to describe root canal morphology in the anterior dentition, maxillary premolars and man-
dibular molars. For the anterior dentition, both Vertucci and Ahmed et al. systems were able to
classify common configurations in maxillary and mandibular incisors; however, non-classifia-
ble Vertucci configuration types were identified in mandibular incisors, which were classified
using the new system [56]. The new system also was able to classify double-rooted canines in a
more accurate manner compared to Vertucci’s classification, which does not consider the num-
ber of roots in the anterior dentition [56].
It has been reported that both systems were able to classify some canal configurations in sin-
gle-rooted maxillary premolars (MP) similarly [53, 58]. However, confusions exist for Vertucci
type IV for single- and double-rooted premolars, which are coded separately using the new
system (codes 2MP B1 P1 and 1MP2) (B: buccal, P: palatal) (Figure 1.16a), in addition to Vertucci
type VIII (three separate canals), which has several presentations in the new system (such as
codes 2MP B1-2 P1, which refers to double-rooted maxillary premolar with a canal configuration
1-2 in the buccal root and one canal in the palatal, and 3MP MB1 DB1 P1, which refers to a three-
rooted variant with three separate roots and one canal in each root [53, 58] (Figure 1.16b).
The literature is limited with regards to the application of the new system in molars [54].
One study used the new coding system to classify mandibular molars in a Chilean population
using CBCT [54]. More studies are needed to provide evidence for its application in mandibu-
lar and maxillary molars in different population groups as well as to classify accessory canals
and anomalies.
Based on evidence from the current literature, it appears that both the Vertucci and Ahmed et
al. classifications are able to address simple root canal configurations similarly; however, the
latter is able to address the number and location of roots in anterior and premolar teeth in addi-
tion to complex and non-classifiable Vertucci configurations in a more accurate manner [55, 56,
58]. Supplementary material is available online showing different applications of the new sys-
tem in laboratory and clinical study models.
1.2.2.5 Applications of the New System in Clinical Practice

The application of the new coding system in clinical practice differs from research, the latter
often being an observational analysis for anatomical features of specific teeth. In clinical prac-
tice, the tooth is subject to two phases – phase one is ‘observational’ where the operator usu-
ally undertakes a pre-operative 2D radiographic view (or CBCT) to study the initial
morphological features of the tooth scheduled for treatment followed by an ‘intervention
phase,’ which includes access cavity preparation, exploration, negotiation, troughing if
required, instrumentation, and filling procedures – or surgery.
The interpretation of root canal morphology could vary through the phases. An example,
based on the 2D pre-operative radiographic image in Figure 1.17, the operator would categorise
this as a double-rooted tooth 36 in which the mesial root (M) appears to have two separate
canals and the distal root (D) appears to have one canal configuration. Therefore, the initial
code for this tooth is 236 M2 D1 (Figure 1.17a). After root canal instrumentation and filling, two
accessory canals were noted in the apical thirds of each of the mesial and distal root (Figure
1.17b). Therefore, the code was eventually 236 M2(A1) D1(A1), which refers to double-rooted tooth
36 in which the mesial root has 2 separate canals and a single accessory canal in the apical third
of the root, while the distal root has one canal and a single accessory canal in the apical third of
the root. Another example is shown in Figure 1.17c,d. This means that the new coding system
can be modified based on the operator’s interpretation along the treatment phases from diag-
nosis to root canal filling – or during surgery.

new coding system for describing
single-, double- and three-rooted
maxillary premolars. Note the
different codes used for Vertucci
types IV and VIII. Reproduced
from Ahmed et al. [219] with
permission.

new coding system in clinical
practice. a) Pre-operative
radiographic image. b) After root
canal filling, two accessory canals
were identified (yellow arrows)
which can be added in the code.
c) Pre-operative radiographic
image of mandibular molar (46).
d) A third distal canal was
identified after further
exploration (yellow arrow).
Reproduced from Ahmed et al.
[220] with permission.
The interpretation of root canal morphology using the new coding system during the obser-
vational phase is important, especially for undergraduate and postgraduate students as well as
GDPs where cases have to be pre-evaluated carefully to fit their level of knowledge and experi-
ence. This means a tooth code 234 B1-2 L1 (double-rooted tooth 34 in which the buccal root is
assumed to have canal configuration 1-2 and the lingual root has one canal) interpreted from
a 2D pre-operative radiograph may not be suitable for an undergraduate dental student, and a
tooth code (RD) 236 M2 D2 (double-rooted tooth 36 in which both mesial and distal roots are
dilacerated – RD – Root Dilaceration) may not be suitable for a GDP. Therefore, the new sys-
tem can play a role in assessing case difficulty at the pre-operative stage, and also can provide
a single code of the tooth after treatment, which may show other anatomical features, such as
accessory canals.
1.2.2.6 Limitations and Technical Challenges

The assessment of apical canal configurations may vary depending on the method used for
identification (experimental or clinical), which can be rather subjective amongst different
observers [10]. For example, based on certain experimental measurements of canal dimen-
sions or clinical negotiability, some apical bifurcations could either be classified as an
apical delta/ramification (i.e. complex ramification of branches of the root canal located
near, and open on, the root apex) or a division from the main canal (type 1-2). To date, a
standard consistent view of such anatomy has not emerged, and therefore, the type of api-
cal canal configuration should be classified based on the method and criteria used for its
identification [10].
The interpretation of canal anatomy using the new coding system (as well as other clas-
sification systems) is highly dependent on the method used (i.e. staining and clearing, 2D
radiographic, CBCT or micro-CT). Indeed, micro-CT is able to show the fine details includ-
ing delicate canal branching and accessory canals, which cannot be seen in CBCT images;
therefore, the coding of the same tooth using both techniques will be different.
1.3 Advances in Apical Canal Morphology
Anatomical challenges and subsequent procedural errors in the apical third of root canals are
associated with less favourable treatment outcomes compared with those that occur in the
coronal third [59]. Therefore, the apical anatomy should be evaluated and understood by cli-
nicians prior to treatment.
The anatomical landmarks of the apical root canal have been investigated since the begin-
ning of the twentieth century. The development of new imaging systems has generated sub-
stantial data to increase knowledge regarding the morphological characteristics of the apical
region of the root and root canal, such as the cemento-dentinal junction (CDJ), apical con-
striction (AC), apical foramen (AF), isthmuses, accessory canals (ACCs), and bifid root apices
(Figure 1.18).
1.3.1 Cemento-dentinal Junction (CDJ)

The CDJ is a structure that can be observed in histological sections; however, clinically and
radiographically, locating the CDJ is impossible. The cementum extends into root canals by
covering dentine and the CDJ is located at various levels around the circumference of the
canal wall in the region of the apical foramen. It is located at different levels within canals in
different tooth types. Usually, the CDJ is not in the same position as the AC, but due to the
deposition of cementum with age, the rate of coexistence at the same point as the AC increases
[60]. There are no odontoblasts in the most apical section of the pulp, where cellular
Figure 1.18 Examples of the

morphological characteristics of
the apical region of roots and
root canals.
cementum lies inside the canal [60, 61]. Although the nature of the tissue found apically is of
academic interest, it has no clinical impact [61].
1.3.2 Apical Constriction (AC)

The AC, also termed the physiological foramen, minor diameter, and minor apical foramen, is
defined as the narrowest diameter of the root canal towards the root apex [30, 62] (Figure 1.19).
However, it is not always present [63–66]. According to many, it is the most suitable apical
reference point within the canal for clinicians to complete canal shaping, cleaning, and filling.
Biologically and logically, resection of pulp tissue at this narrowest point causes less inflamma-
tion [67]. Additionally, during root canal procedures, this narrowest point is thought to reduce
the potential undesirable effects of endodontic procedures or materials on periapical tissues
[67, 68].
These reasons make the AC clinically relevant. Several studies have examined the location
of AC and its topography using various techniques [62, 65, 69, 70]. However, the absence of a
standard for studies that aimed to reveal the presence and location of the AC, along with the
different perspectives among researchers, has led to different results regarding its existence.
To date, the smallest diameter in longitudinal sections of the apical canal or the smallest area
of apical canal in horizontal sections was used to detect the AC. In some studies using longi-
tudinal sections, the parallel and flared types of apical canal were considered to have no con-
striction [63–65], whereas the AC can be detected as the narrowest cross-sectional area of the
canal in parallel and flared types of apical canal [71].
The bulk of information on the position and shape of the AC is based on inspecting and
measuring the smallest diameter in longitudinal sections of apical root canals. The longi-
tudinal sectioning method is sensitive and vulnerable to procedural errors; detection of the
direction of the longitudinal section has no standard methodology or criteria for defining
the landmarks, and excess removal of dentine may result in inaccurate measurements [72].
In addition, the individual operator is responsible for carefully detecting and measuring
the narrowest point of the canal. Thus, this method is greatly influenced by their experi-
ence. Also, ovality, complexity, and multiplanar curvatures of root canals pose major chal-
lenges for the accurate investigation of the AC in longitudinal sections. Clearly, the section
must be at the centre of the canal throughout the canal axis to allow accurate
measurements.
Currently, micro-CT technology is considered the most accurate research tool used to study
root canal anatomy [73]. This non-invasive, non-destructive, high-resolution technology
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Endodontic Advances and Evidence Based Clinical Guidelines 1St Edition Hany M A Ahmed Full Chapter

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Library of Congress Cataloging-in-Publication Data

Part I: Advances in Knowledge 1

1 Tooth, Root, and Canal Anatomy 3

2 The Bioactive Properties of Dentine and Molecular Advances in Pulp

ftoc.indd 5 21-09-2022 20:06:39

3 Microbial Biofilms in Root Canal Systems 74

4 Pulp, Root Canal, and Periradicular Conditions 85

5 Root Resorption 117

ftoc.indd 6 14-09-2022 18:26:42

5.4.2 External Replacement Resorption 122

6 Minimally Invasive Endodontics 130

7 Systemic Health and Endodontics 153

ftoc.indd 7 14-09-2022 18:26:42

7.5.1 Scientific Evidence on the Association Between Cardiovascular Diseases and

8 Technology Enhanced Education 178

Part II: Advances in Materials and Technology 191

9 Computed Tomography Imaging Devices and Techniques 193

10 Advances in Working Length Determination 218

ftoc.indd 8 14-09-2022 18:26:42

10.4 An Overview of Basic Electronics 222

11 Advances in Materials and Techniques for Microbial Control 243

12 Nickel-Titanium Metallurgy 268

ftoc.indd 9 14-09-2022 18:26:42

12.3 Surface Treatment of NiTi Alloys 272

13 Rotary and Reciprocating Motions During Canal Preparation 283

14 Hydraulic Calcium Silicate-based Endodontic Cements 311

15 Nanomaterials in Endodontics 347

ftoc.indd 10 14-09-2022 18:26:42

15.3.1 Application of nanomaterials for Endodontic Disinfection 350

Part III: Advances in Clinical Management 367

16 Vital Pulp Treatment 369

17 Detection of Canal Orifices, Negotiation, and Management of Calcified and Curved

ftoc.indd 11 14-09-2022 18:26:42

17.3.4 Clinical Strategies for the Negotiation of Complex Canals 416

18 Management of Fractured Instruments 440

19 Repair of Pulp Chamber and Root Perforations 475

ftoc.indd 12 14-09-2022 18:26:42

19.7 Surgical Management of Perforations 499

20 Removal of Root Canal Filling Materials 511

21 Restoration of Root-filled Teeth 565

ftoc.indd 13 14-09-2022 18:26:43

21.6 Importance of the Final Restoration 582

22 Classifications and Management of Endodontic-periodontal Lesions 591

23 Management of Coronal Discolouration 617

24 Surgical Endodontics 645

ftoc.indd 14 14-09-2022 18:26:43

24.4.3 Mucoperiosteal Flap 648

25 Alternatives to Root Canal Treatment: Tooth Autotransplantation 669

Part IV: Evidence-based Clinical Guidelines 685

26 Endodontic Diagnosis 687

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26.2.3 Medical History 689

27 The Use of Cone-Beam Computed Tomography in Endodontics 719

28 Endodontic Emergencies and Systemic Antibiotics in Endodontics 734

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29 Revitalization Procedures 749

30 Management of Traumatic Dental Injuries in the Permanent Dentition 761

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Paul V. Abbott Umm Al-Qura University

6 Minimally Invasive Endodontics 130

7.5.1 Scientific Evidence on the Association Between Cardiovascular Diseases and

17 Detection of Canal Orifices, Negotiation, and Management of Calcified and Curved