Manejo Del Tercio Apical en PowerPoint

7/27/2019 Manejo Del Tercio Apical en PowerPoint

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Management ofthe Apical Third

The greatest enemy of truth is

very often not the deliberate,

contrived and dishonest, but themyth persistent, persuasive, and

unrealistic.

We enjoy the comfort of opinion

without the discomfort of

thought. John F. Kennedy

How We Manage

the Apical Third

Does it matter?

Apical Third Histology Historical Concepts

The CDJ as a dividing line is

imaginary (Coolidge, 29) Canals should be filled to the CDJ

(Skillen, 30)

Canals should be slightly overfilled

(Blayney, 27)


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Apical Third Anatomy

Classic Concept

Kuttler 55

Reality

Dummer 84; Ainamo & Le 68

Madsen et al 00; Meder et al 09

Kuttler JADA 1955

(A myth?)

Apical Morphology of Maxillary Molars

Using Microcomputerized Tomography

Meder-Cowherd L, Williamson A, Johnson W

In Preparation for Publication, J Endod 2010


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Materials and Methods

Shape of apical canal anatomy determined

Generated micro-computerized 3-D images Analyzed maxillary molar palatal roots

Selected images giving best view of apical canal

Analyzed by trained and blinded evaluators

Determined shape of apical canal anatomy

Categorized into configuration groups

Results

Apical anatomy highly variable

Several shapes of apical constriction

Parallel 35%

Single 18%

Tapering (Classic) 15%

Flaring 18%

Delta 12%

Frequent deviation of foramen from apex

Anatomy of Structures in the

Apical Region of the CanalA Histologic Evaluation

R. Madsen

L. Baldassari-Cruz

R. Walton(Abstract) J Endod 2000

Materials and Methods

Teeth and apical tissues removed from cadavers

Histologically prepared

Longitudinal sections to include apical 1/3 of canal

Determined were:

Location of apical foramen, apical constriction

Anatomy of apical constriction

Relationship of CDJ with apical constriction

Comparison with Kuttlers findings and diagram

Results Apical Constriction

Frequently not present

When present, shape and canal level variable

Cemento-Dentinal Junction Levels highly variable

Difficult to interpret

No specimen matched Kuttlers diagram


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Multiconstricted Flared

Apical anatomy often altered because of

apical pathosis and root resorptionIn Summary:

Kuttlers concept diagram likely does not occur

When present, the apical constriction is highly

variable

Frequently, there is no constriction

There is no clinical technique to evaluate presence

of constriction or shape of apical anatomy

The apical constriction should not be used as a

landmark for C&S or obturation

Apical Canal Anatomy

The apical few millimeters is variable inshape in cross-section

Many apical canals are flattened(ribbon-shaped)

May be multiple foramina

Frequent deviation from apex

Gani & Visvisian JOE 1999

Wu et al OOOOE 2000

Soma et al IEJ 2008

Martos et al IEJ 2009 Ganni and Visvisian 99; Wu 00


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Apical Canal Structure Marked variations

Accessory canals, resorptions, repair,

pulp stones, irregular secondary

dentin

Cementum-like tissue on canal walls

Mjr et al IEJ, 2001

Apical Third Histology

Classic Concept

Reality

Aberrations in the Apical Third

Frequency

Can they be debrided?Can they be obturated?

Does it matter?

Lateral Canals

Frequency

Can they be debrided?Can they be obturated?

Does it matter?


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Frequency and Location

Frequency high

Most in posterior teeth

Predominance in apical 1/3

Degerness and Bowles J Endod 2008

Apical Delta


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Can Lateral Canals be

Obturated in the Apical Third?

Canals prepared thenobturated with Schildertechnique

Roots were cleaned

Very few lateral canals filledwith gp and/or sealer

Venturi et al IEJ 36:54, 2003

Are Lateral Canals and Apical

Ramifications Debrided and Filled?

Apparently not

Teeth with RCT extracted

Roots prepared histologically

LCs and ARs examined for tissue, obturating

materials and bacteria

Results: LCs and ARs not debrided and

seldom contained obturating material

Ricucci, Siqueira. J Endod 36: 1, 2010


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Does It Matter If Lateral Canals are

Debrided and Obturated?

Apparently not

Block sections of apical regions in root-filledteeth were examined in cadaver jaws

All roots had lateral canals

No lateral canals contained obturatingmaterial

No relationship was detected betweenunfilled lateral canals and the status ofinflammation at the periapex

Barthel, Zimmer, Trope. J Endod 30:75, 2004

Intracanal Isthmi

FrequencyCan they be debrided?

Can they be obturated?

Does it matter?

Apical Patency

What is it?

What is the technique based upon? What are the advantages?

What are the disadvantages?


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How will small patency files behave?


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Patency File and Apical

Transportation

#s 10, 15, 20 and 25 patency files Precurved SS and NiTi hand files

Files used sequentially

Transportation seen with each file

size

Goldberg & Massone J Endod 28:510, 2002

Effect of Maintaining Apical Patency

on Canal Transportation

Compared different preparation techniques

Lightspeed rotary with and without patency files Balanced force hand with and without patency

Results:

All techniques produced transportation

No difference between groups

Tsesis et al IEJ 2008

Apical Patency: Other considerations?

Post-treatment pain? No effect

Arias et al J Endod 2009

Success rate? Not determined

Tissue damage?

Not determined, however

Updated recommendations for managing

the care of patients receiving oral

bisphosphonate therapy. JADA 2009

For endodontic procedures:

Manipulation beyond the apex is not

recommended

Apical Patency in Summary:

Has no biological rationale

Likely

does not accomplish the stated objectives

damages periapical tissues

does not improve outcomes

Has no effect on postreatment pain

Aspects of Apical Third

Preparation

Apical Clearing

Size of Preparation


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Does Increased Enlargement Reduce

Bacteria and Improve Debridement?

Yes Tan & Messer. JOE 2002

Card et al. JOE 2002

Usman et al. JOE 2004

Baugh & Wallace. JOE 2005

Heish et al. IEJ 2007

No (when initially to a larger size) Coldero & Saunders. IEJ 2002

Bacteria in the apical third

Before

Oval Canal Necrotic

Debris

After

Round Canal Clean and

Ready for

Obturation

Apical Clearing


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Effectiveness of Apical

Clearing: Histologic and

Morphologic Evaluation

Parris J, Wilcox L, Walton R J Endod 20:219, 1994

Apical Clearing Procedure

Final apical preparation (enlargement)

Irrigant present in canal

Files 3-4 sizes larger than MAF rotated at WL

Canal irrigated

Canal dried with paper points

Final apical reaming (Dry Reaming)

Largest file rotated at WL


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Possible Advantages of Apical

Clearing

Maximize debridement

Deeper penetration of irrigating

needle/solution

Increase size of apical preparation

Improved obturation

Objectives

Debris removal and walls planed

Apical transportation

Compare effectiveness of step-backwithout apical clearing vs. step-

back with apical clearing for:


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Conclusions

Apical clearing resulted in better

debridement

Apical transportation was found in

both groups; more in the apically

cleared group

Why is there minimal transportation?

What About the Smear Layer?

Studies generally favor removal

NaOCl alternated with EDTA best

Deep needle penetration

Special irrigating devices?

Apical third less predictable removal

Messer

Uroz-Torres et al. J Endod, 2010

Violich, Chandler. Int Endod J, 2010

What About Apical Preparation Size?

R Madsen


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Root Canal TreatmentRoot Canal Treatment

Looks Good?Looks Good?

Length OKLength OK

Shape OKShape OK

Why did it fail?Why did it fail?

LetLets extract and sections extract and section------

Courtesy Dr S Senia

Mesial root - 1 mm from apex

necrotic tissue and debris

Mesial root - 2 mm from Apex Distal Root - Foramen

Poor obturationPoor obturation

Distal Root - 1 mm from Apex

Necrotic tissue and debris

Canal notCanal not

instrumented to theinstrumented to the

correct diametercorrect diameter

Distal Root - 3 mm from Apex

Necrotic Tissue and Debris


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Nair R. In: Pathways to the Pulp 2006

Working Length

ConsiderationsPrognosis

Periapical Response

Post-treatment Symptoms

Systemic Impact

Considerations

PrognosisPrognosis

Periapical Response


Systemic Impact

PrognosisExtrusion of

Obturating Material

An irritantRelated to decreased

success Nair R. Pathways of the Pulp,

2006

Torabinejad & Siggurdson.

Endodontics: Principles and

Practice 2009


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Determining Optimal Obturation

Length: A Meta-analysis of Literature

Short of the radiographic apex

had better success than long

Preferable to err on the short side

than be long (uncertain about

sealer extrusion only)

Schaeffer, White, Walton. J Endod 2005

Evid Based Dent 2005

Prognosis

Long-term Studies Show: Optimal result: end preparation and

obturation within radiographic apex

Too short, success rate drops

Beyond apex, an even poorer result

Gutmann & Witherspoon, Pathways to

the Pulp, 8th ed. 2002

Prognosis

Success rate of endodontic treatment of teeth with

vital and nonvital pulps. A meta-analysis

No difference between vital and non-vital pulps

Failure rate greater with a lesion present

Success much lower with obturation overextension than

with flush or underextension

Conclusion: The root canal should be filled to within

2mm of the radiographic apex.

Kojima K et al. OOOOE 97: 95, 2004

Considerations

Prognosis

PeriapicalPeriapical ResponseResponsePost-treatment Symptoms

Systemic Impact

Tissue Injury and Inflammation

from:

Instruments

Irrigants

Medicaments

Obturating Materials


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Termination of Preparation and

Obturation


Short of the apical foramen Review: Ricucci, Langeland, Int Endo J, 1998


Obturation

Vital pulp: 1-3 mm short Necrotic pulp: 0-2 mm short

Wu, Wesselink, Walton OOOOE 2000


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Techniques of Canal Preparation

StandardizedFlaring

Stepback

Crown-down

Rotary

Debridement of the Apical Third

Hand tends to debride better than

rotaryApical canals are variable in shape

Uninstrumented, undebrided areasare common

Ahlquist et al IEJ, 2001

Barbizam et al JOE, 2002

Wu & Wesselink IEJ, 2001

Rdig et al IEJ, 2002

Shaping of the Apical Third

All techniques tend to transport

Factors (curvature, size, shape) are

important

Different instruments and

techniques cause variability Peters et al J Endod, 2001

Imura et al J Endod, 2001

Ahlquist et al Int Endod J, 2001

Hartmann et al J Endod, 2007

Moore et al Int Endod J, 2009

ObturationLength

Technique

Cold Lateral

Warm Vertical

Other


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Tissue Reaction to Obturation

Short of the apex little

responseBeyond the apex

Inflammation

Delayed healing

Ricucci & Langeland, IEJ, 1998

Guttmann & Witherspoon, 2002

Extrusion of Debris

Compared NiTi rotary (Lightspeed & ProFile

.04) and stainless steel hand (step-back &balanced force)

Determined amount of debris extrusion

All techniques produced apical debris

Overall, NiTi rotary extruded the least

Reddy S & Hicks L. JOE, 1998

Considerations

Prognosis

Periapical Response

PostPost--treatment Symptomstreatment Symptoms

Systemic Impact

Post-Canal Preparation Symptoms

Canal preparation with either SS hand or NiTi

rotary

Determined pain levels and pain incidence

No difference in the groups

Aqrabawi J et al. J Dent 2006

Post-Obturation Symptoms

48% reported symptoms after

obturation

10% or less significant symptoms Overfill (no lesion) more pain

Harrison et al. JOE, 1983

Considerations

Prognosis

Periradicular Response


Systemic ImpactSystemic Impact


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Systemic Considerations

Oral Microbes and Disease

Bacteremia

Inducing Bacteremia

Factors that produce

bacteremia

Necrosis

Over-instrumentation

Impact

Bacterial Extension

Pulp Necrosis

Apical Foramen

Short Close

Beyond

Bender et al, Oral Surg, 60

Baumgartner et al, JOE, 76

Overinstrumentation and

Bacteremia

Periradicular Contamination Gutierrez et al., 1999

Intracanal Bacteria in Blood Debelian and Tronstad, 1998

Ayub et al IEJ 2007


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Updated recommendations for managing

the care of patients receiving oral

bisphosphonate therapy. JADA 2009

For endodontic procedures:

Manipulation beyond the apex is not

recommended

In Conclusion

Apical canal anatomy and histology are

variable and indeterminable, clinically

Instruments, materials and chemicals

should be confined to the canal

Conclusions (continued)

Lengths should be 1-3 mm short of the apex

Aberrations are inconsistently debrided

Debris in the apical canal preparation should be

reduced before obturation

Apical canal preparation should be at least #40

There is no superior instrumentation technique


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Periapical Tissue Injury and

Inflammation Occurs from:

Instruments

Irrigants

Medicaments

Obturating Materials


Obturation

Vital pulp: 1-3 mm short

Necrotic pulp: 0-2 mm short


Obturation


Short of the apical foramen

Bacterial Extrusion Beyond the

Apex Will Produce:

Periapical inflammation

And May Produce:

Systemic disease

FinallyWe need more definitive

information based on:

Scientific data

Evidence-based research

Outcomes assessment


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Good clinical decisions require

scientific accuracy to avoid bias

Clinical significance is the

consideration of risk vs. benefit

Important outcomes (success) of

therapy are measured by a

combination of evidence-based

criteria, clinical judgment and

common sense.

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