The Root Apex

Presentation by
Dr. M SUMANA
pg in dept. of

Contents
Introduction
Root development
Anatomy of root apex
Age changes
Clinical significance of root apex
Conclusion
References

INTRODUCTION
Morphologically - most
complex .
Therapeutically - most
challenging.
Prognostically
important.

most

ROOT DEVELOPMENT

Root development begins after enamel and dentin formation has

reached future CEJ

HERTWIGS EPITHELIAL
ROOT SHEATH
Consists of outer and
inner enamel epithelium.

Moulds the shape of roots

initiates radicular dentin
formation.

Cells of inner epithelia induce the differentiation of

radicular cells into odontoblasts.
HERS loses its continuity when first layer
of dentin
is laid
Coronal
Coronal dentin
dentin
down.
Enamel
Enamel
Ameloblasts
Ameloblasts
Stratum
Intermedium
DEJ
DEJ
Future
Cemento
Cemento
enamel Epitheli
Epitheli
Junctional
al rests
rests
of
of
Malasse
Malasse
Disintegrati
Disintegrati
zz
on
on of
of
Hertwigs
Hertwigs

Odontoblasts
Odontoblasts
Pulp
Pulp
Root
Root Dentin
Inner
Inner
enamel
enamel
epithelium
epithelium

Epithelium is moved away from surface of dentin.

connective tissue comes in contact with dentin and
differentiates into cementoblasts

In multirooted teeth-root sheath forms epithelial

diaphragm.
It bends at future CEJ into a horizontal plane.

Apical Root Anatomy

The classic concept of apical root

anatomy is that there exists three
anatomic and histologic landmarks

Apical foramen/major diameter.

Apical constriction/Minor diameter.
Cemento dentinal junction.

Anatomic apex/true apex :It is the vertex or tip of the root seen
morphologically.
Radiographic apex: Tip or end of the root determined
radiographically.
Apical foramen/major diameter : It is the main apical opening of
the
root canal.it is frequently eccentrically located away from the
anatomic and radiographic apex

 Apical constriction/minor

diameter: It is the apical portion

of the root canal having the
narrowest diameter.

Cementodentinal junction- It is

the region where dentin meets

the cementum,from here the
pulp tissue ends and
periodontal tissue begins .

Radiographic terminus -It is

defined as end of the canal

shown on the radiograph

Root canal tapering from the canal orifices

to the apical constriction which is generally
0.51.5mm inside the apical foramen

The diameter of the apical foramen in the age

range of 1825 was 502m and over 55
years of age was 681m, demonstrating its
growth with age.

The shape of the space between the major and minor

diameters has variously been described as funnelshaped, hyperbolic or 'morning glory'.
The mean distance between the major and minor
diameters is 0.5mm in a young person and 0.67mm in
an older individual.
The increased length in older individuals is due to the
increased buildup of cementum.

Inadequate knowledge and mismanagement of apical foramen

may affect long and short term success of RCT.
Location and shape of fully
formed apical foramen vary in
each tooth and in same tooth at
different periods of life.
May change due to
functional influencesocclusal pressure, mesial
drift,tongue pressure.

(A) Major apical foramen (apical

opening) with protruding
instruments.
(B) Root apex.

Shape
Briseno Marroquin et al. Investigated
the apical anatomy of 523 maxillary and
574 mandibular molars from an Egyptian
population.
The most common physiological foramen
shape was oval (70%).

Results published previously in: Morfis A, Sylaras SN, Georgopoulou M, Kernani M, Prountzos F. Study
of the apices of human permanent teeth with the use of a scanning electron microscope. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1994: 77(2):172176.
*

Apical Constriction

amen is not always the most constricted part of canal

Ideally the root filling should stop at
this constriction as it would serve as an
apical dentin matrix-

Dentin

Minor Apical
Diameter
Major Apical
Diameter

DUMMERS CLASSIFICATION

Significance:
Natural stop during root canal preparation and filling.
Precautions should be taken to maintain size of
constriction and patency of foramen.
Should not be enlarged nor blocked
working length should be measured correctly
canal patency maintained through recapitulation
adequate irrigation to prevent accumulation of
dentin

CEMENTO DENTINAL JUNCTION(CDJ)

The CDJ is the point in the canal where cementum meets
dentine.
Histological landmark, cannot be located clinically or radio
graphically.
ACCORDING TO KUTTLER(1958)
Root canal is divided into a long conical dentinal portion and a
short funnel shaped cemental portion.
Cemental portion is in the form of inverted cone with its
narrowest diameter at or near CDJ and base at apical foramen.

Theoretically, the CDJ is the appropriate apical limit for root canal
treatment as at this point the area of contact between the
periradicular tissues and root canal filling material is likely to be
minimal.
(Palmer et al. 1971, Seltzer 1988, Katz et al. 1991, Ricucci &
The term theoretically is applied here because the CDJ is a
Langeland 1998)
histological site and it can only be detected in extracted teeth
following sectioning, in the clinical situation it is impossible to
identify its position.
In addition, the CDJ is not a constant or consistent feature, for
example, the extension of the cementum into the root canal
can vary (Ponce & Fernandez 2003).
Therefore, it cannot be an ideal landmark to use clinically as

ACCESSORY AND LATERAL CANALS

Lateral canal is located at right angles to main root canal .
Accessory canal branches off from the main root canal in the
apical region.
Furcation canal seen at furcation.

According to HESS et al (1963)

Accesory canals have a mean diameter of 6-60 m.
Accessory canals form apical deltas in the root apex.
In distal root of mandibular molars and palatal of maxillary
molars these canals fan out towards the apex in a canoe
shaped arrangement.

These canals are avenues for interchange of metabolic and

breakdown products between pulp and periodontal tissue.
If present in the floor of pulp chamber these canals transmit
toxins and irritants from pulp cavity and establish a lesion in
furcation which may appear radiographically as periodontal
disease

They are usually not detected in intraoral radiographs.

They may become noticeable following necrosis of the main
canal
Thickening of the PDL or development of a frank lesion in the
lateral wall of the root
Also become apparent in the post obturation x-ray where radioopaque material is seen extending to surface of root.

F.J Vertucci(1884)
Teeth No.Of
Lateral
Teeth
Canal
Examin %
ed

Apical
3rd

Middle
3rd

Cervica
l 3rd

100

24

93

100

26

91

100

30

90

10

400

49

74

10

200

59

78.2

16

Mb -100
Db -100
P
-100

51
36
48

58
59
61

13
12
11

10
10
9

Mb -100
Db -100
P -100

50
29
42

65
67
70

14
13
11

10
9
8

Presence of these canals emphasize the need for employing

effective irrigation solution and technique and also three
dimensional filling of root canal.
Also when the pulp is extirpated from a vital tooth ,pulp stump
may remain in these canals causing post-pulpectomy pain
and also pain felt when sealer is pushed into these canals

These canals may harbor micro organisms and continue to

irritate periapex .
Lesion may grow despite radiographic evidence of proper filling
of principal canal.
These cases require periapical surgery.

Presence of multiple accessory and lateral canals is the rule and

not the exception as evident from various studies.
The number of accessory canals does not appear to be significant
in the success or failure of RCT teeth.

According to HESS(1983)
Following endodontic therapy in teeth with vital pulps the lateral
and accessory canals become obliterated by the deposition of
cementum with the passage of time.
In non-vital teeth, inflammatory tissue will get resorbed and
replaced with uninflammed connective tissue.

Although the incidence of occurrence of these canals is high the

percentage of failures due to unfilled canals is small in clinical
practice.
This is because of the biological hard tissue closure(cementum)
subsequent to the elimination of chronic inflammation and
irritants from main canal

APICAL DELTAS
The principal canal may not exit as a single apical foramen,in
many instances it may slit near the apex and exit in two or more
smaller foramina this y shaped branching is called apical
delta
Following
endodontic
treatment,
the
pulp
tissue
in
uninstrumented branches may become inflammed but usually
retains its vitality with passage of time, continuous deposition of
dentin or cementum tends to narrow the Lumina of these canals.

CANAL CURVATURE

d of roots are complex also in curvature.

eth show a distal curvature in apical third.

or lingual curvature may not be discernible in radiograph.

URVATURE FORMATION
When tooth erupts into oral cavity its apex is not completely
formed
As the tooth becomes functional it is subjected to biting stresses
which may move the tooth mesially.
This slow bodily movement of the incompletely formed tooth is the
cause of curvatures in the apical third of the root.

Clinical management
Preflaring of the coronal part of canal facilitates the proper
instrumentation of apical curvature.
Prebending of files during instrumentation improves the
negotiation of the curvature.
Failure to do so results in ledging ,ripping,iatrogenic canal
formation or perforation

Type Of Root Apex

THIN PINCHED APEX
Proper care required during instrumentation
Over enlargement may lead to perforation

BULBOUS
APEX
Usually due to hypercementosis
Proper care required during length determination
Apical constriction is significantly shorter from

radiographic apex

Resorbed Apex
Caused due to advanced inflammation at the periapex
Resorption of cementum and dentin and widening of apical foramen
WL determination ,preparation and condensation of guttapercha is
difficultPreparation should stop 1-2mm short of radiographic apex.

BLUNDERBUSS APEX
Newly erupted tooth showing an incompletely formed root

having a wide canal and an open apex.

The pulp may get necrosed due to carie or trauma and may

require root canal therapy

Standard instrumentation and obturation techniques are not

favorable

of canal are thin and fragile.

acks apical constriction

ment depends on the condition of pulp :

al apexogenesis is done

nvital -apexification or peri-apical surgery required

AGE CHANGES

REMODELLING/DEPOSITION OF CEMENTUM AT THE APEX IS

AN AGING PROCESSOccurs to compensate for attrited enamel or Physiological
mesial migration of tooth

ROOT APEX AND ITS

CLINICAL SIGNIFICANCE

Working Length
One of the main concerns in root canal treatment is to determine
how far instruments should be advanced within the root canal
and at what point the preparation and filling should terminate.
Cleaning shaping and obturation cannot be accomplished
accurately unless working length is determined precisely.

When correct working length is not maintained

Working length short results in

Incomplete cleaning
Allows pulp tissue and necrotic debris to remain in the
canal
Persistent discomfort as the pulpal remnants are left behind.
Under filling
Incomplete apical seal .
Apical leakage which supports the existence of viable
bacteria and contributes to periradicular lesion and hence

Failure to accurately determine and maintain the working length

may result in
Perforation through the apical constriction
destroys the delicate apical region of the canal and can cause
potential damage to the periapical tissues
Increased incidence of post operative pain
Delayed healing

APICAL END OF WORKING LENGTH?

CDJ
Not clinically identifiable
Inconsistent
Therefore not used as the apical stop in clinical

practice
Minor Diameter
Minor apical foramen is a more consistent

anatomical feature that can be regarded as being

the narrowest portion of the canal system
Preferred landmark for the apical end-point.

ACCORDING TO KUTLERThe narrowest diameter(AC) of the canal is definitely not at the site of exit
of the canal from the tooth ,but usually occurs within the dentin, just prior
to the initial layers of cementum.
He referred this position as the minor diameter.
This is the site that is preferred to terminate canal preparation and build up
the apical dentin matrix.

Methods To Determine
Working Length
Conventional methods

Advanced methods

Radiographic method
method
Digital tactile sense
Apical periodontal
sensitivity
radiography
Paper point method
Radiographic grid
radiography

Electronic
Direct digital
Xeroradiography
Subtraction

GROSSMANS METHOD
Instrument placed in root canal extending till apical constriction using
tactile sense
Radiograph is taken
Measure radiographic lengths of tooth & instrument &
calculate actual length of tooth using the formula
Actual length of tooth = Actual length of instrument length of
tooth
Radigraphic length of instrument

INGLES METHOD
The tooth is measured on a good preoperative radiograph
Tentative working length.

As a safety factor, allowing for image distortion or magnificatio

subtract at least 1 mm from the initial measurement
The instrument is set with a stop at this length.

FINAL WORKING LENGTH

The instrument is inserted to this length and a radiograph is
taken.
On Radiograph is measured diff b/w end of instrument and
end of root.
This is added to the tentative working length.
From this measurement 1mm is subtracted as adjustment for
apical termination.

WEINES
RECOMMENDATION
1mm from apex -no bone or root resorption
1.5mm from apex -only bone resorption
2mm from apex -both bone and root resorption

APICAL PERIODONTAL SENSITIVITY

Based on the patients response to pain when reaching
the periradicular tissues
Not an ideal method

PAPER POINT MEASUREMENT

Uses conventional absorbent paper points.
And it is based on the assumption that when the contents of the
root canal system are removed, the canal should be dry, while the
environment outside the root canal is living and hydrated.

DIGITAL TACTILE SENSE

Clinician may detect an increase in resistance as the file
approaches the apical 2 to 3 mm.
This detection is by tactile sense. In this region, the canal
frequently constricts (minor diameter) before exiting the root.

ELECTRONIC APEX
LOCATORS
A new level of accuracy in length determination over
radiographs has been achieved with the electronic apex
locator (EAL)
The EAL is free of the problems that visual
interpretation of two-dimensional radiographs present.
Unfortunately, the EAL is not 100% accurate

HOW APEX LOCATORS FUNCTION

Use the human body to complete an electrical circuit.
One side of the circuitry is connected to an endo
instrument & the other end to the patients body-- patients
lip or by an electrode held in the patients hand.

Their functionality is based on the fact that the electrical

conductivity of the tissues surrounding the apex of the root is
greater than the conductivity inside the root canal system
provided the canal is either dry or filled with a nonconductive
fluid

ADVANTAGES
Decreases patient exposure.
Used when radiographs are difficult to read.
Used to detect perforations.
Easy and fast.
Can be used in pregnant patients, children, patients with
gag reflex.

DISADVANTAGES
Not 100% accurate
Not useful in immature teeth
May show inaccurate readings
Cannot be used in patients with cardiac pacemakers

WORKING WIDTH

Introduction
The most important objective of root canal therapy is to
minimize the number of microorganisms and pathologic debris
in root canal systems to prevent or treat apical periodontitis.
Thorough instrumentation of the apical region has long been
considered to be an essential component in the cleaning and
shaping process.
It was discussed as a critical step as early as 1931 by Groove
Simon later recognized the apical area as the critical zone for

SIGNIFICANCE
Horizontal dimension of RC system more complicated than
vertical dimension
Horizontal dimension of RC system more complicated than
vertical dimension
In principle, however, preparing each canal to a specific apical
diameter as per its initial apical size may better equip the
clinician to provide a more predictable canal preparation.

Size of the apical preparation:

Determine the pre-operative canal diameter by passing consecutively larger
instruments to the WL until one binds
The first size that binds at the working length is called the initial apical
file (IAF)

Factors Affecting The Determination Of

Minimal Initial Apical Width.
Canal shape.
Curvature.
Length.
Content.
Canal wall irregularities.
Taper.

Final Width Of Canal

The classic test for determining correct width
finding of clean, white dentin shavings on the
flutes of the reamers and files.
But, does not necessarily indicate thorough removal of tissue,
debris, and affected dentin
Many canals are oval or ribbon shaped in cross section. Clean,
white dentin shavings are attainable from walls close to each
other, but the far walls may be completely untouched while this

According to Weine,
The master apical file size is suggested to be the three ISO file sizes
larger than the initial binding file.
The file three sizes larger than the first file that binds is called the
master apical file (MAF)

Studies suggested that root canal have not been thoroughly cleaned
even after being enlarged 3 size greater than their original
diameters.
Jou YT, Karabucak B, Levin J, Liu D. Endodontic working width: current
concepts and techniques. Dent Clin North Am 2004;48:32335.

Procedural Errors Seen At The

Root Apex

Procedural accidents in endodontics are those

unfortunate
occurrences
that
happen
during
treatment, some due to inattention to detail, and
others totally unpredictable
Type of errors
Ledging
Apical Transportation
Perforation

LEDGING
Any deviation from the original canal curvature results in the
formation of a ledge.
CAUSES
Inadequate access cavity preparation
False estimation of pulp space direction
Failure to pre-curve SS instruments
Failure to use instruments in a sequential manner
Attempt to retrieve separated instruments

Recognition:
` A ledge is suspected when the root canal instrument can
no longer be inserted into the canal to full working length
Prevention:
Pre-curving instruments and not forcing them is a sure
preventive measure.

APICAL TRANSPORTATION
Moving the position of the position of the canals physiologic
terminus to a new iatrogenic location on the external root surface
is called transportation of the foramen.
Correction:
Mineral trioxide aggregate is barrier of choice.
In severe cases where barrier technique
cant be created corrective surgery is required.
Prevention:
Correct determination of working length

PERFORATION
An artificial opening in a tooth or its root , created by
boring, piercing ,or cutting, which results in a
communication between the pulp space and the
periodontal tissues
Incidence

3-10%

Apical perforations
This type of perforation occurs through the apical foramen or
through the body of the root.
Etiology:

Instrumentation of canal beyond the apical foramen.

Incorrect WL or inability to maintain proper WL causes blowing
out of the apical foramen
Treatment: establish a new WL, creating an apical seat and

obturating the canal to its new length. The new WL should be

ZIPPING OR ELLIPTICATION
Transportation or transposition of the apical portion
of the canal.

CONCLUSION
The crux of endodontics revolves around efficient & effective
manipulation & obturation of the apical third
Appreciable knowledge of the morphology of the root apex and its
variance, ability to interpret it correctly in radiographs, and to feel
it through tactile sensation during instrumentation are essential
for an effective rendering of the treatment of root canals.

REFERENCES

Cohens pathways of pulp -9th and 10th edition

INGLES endodontics 6
Grossmans endodontic practice
Endotopic 2005 ,10-root conal morphology and its
relationship to endodontic procedure(f.j vertucci)
DCNA 2004 (cleaning and shaping) jou yt, et al.