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Endo Questions for the RWE Faculty:

In this area, users are encouraged to ask questions from the RWE Faculty regarding Endodontics in General and the EndoSequence Technique.

Endo Questions for the RWE Faculty:: apical calcification

Missing

Joined: May 2015

Rank: Sergeant

Posts: 3

#1
Hi There,
hope every member of ROE is doing fine
I have a question regarding ( calcified apical third )  many cases in endo we start with access opening locate the canals and trying to achieve patency, it easily achieved in the coronal one and middle third, but once trying to further down it is cannot go further ,taking an IOPA it shows no continuity of that canal ,then we think of many things sudden curvature ,too narrow canal,, etc  then the failing adventure will start back and forth from one file to another and irrigation but to no avail the preparation will start to whatever length was achieved and obturation will be short 3 or 4 mm and the justification will be "it was calcified " and after a couple of month or years it ends up with a lesion and the endodontist  miraculously will do a complete bmp and obutration !!!


to summarize that

is  apical calcification is a myth or reality ?? when and how to identify ??
if my file is 3 mm short of apex and i cannot see the rest of the canal is it calcified ?? 
many textbooks blame on debris and uncomplete removal of the pulp ??
can we have an apically  calcifed  canal WITHOUT coronal ?? what about the process of the calcification apically or coronally any difference ??  
 many deny the apical calcification and say that it is iatrogenic ??
hope to see an answer and hopefully a great video like the "the myth of the mb2 canal "

regards

 




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Joined: November 2013

Rank: Faculty General

Posts: 43

#2
In reply to mohammed abed While apical anatomy can be unpredictable, most of the time the apex does not calcify. There could be a sharp turn, a bifurcation, ledge creation or debris packing that prevents the operator from reaching apex. 
Doing crown down and managing loose debris is key in increasing your chances of reaching the apex. Inability to reach apex should be a rare event. If it's happening to you more frequently than it should, you may need to take a look at your instrumentation technique and how you get down. It's not an easy answer but while apical calcification can happen due to cementum ingrowth, this is rare and often associated with periodontally involved teeth. Most of the time, iatrogenic events are the source of this kind of blockage. There's always a canal, that's how the blood vessels and nerves reach the pulp chamber, the question is if this space can remain patent as you go down. That's the art of it. I recommend practicing on extracted teeth a little to gain experience in managing apical anatomy. 
Allen_ali_nasseh

Joined: August 2013

Rank: Faculty General

Posts: 299

#3
In reply to mohammed abed If the root canal was vital at some point, then there must have been a place where the pulpal soft tissue was present and was nourished by the apical vasculature. So, there's always patency at the level of the vasculature. The question is whether it's patent at the level of an endodontic file! 
Unfortunately, there are way too many factors come to play to decide whether a canal is patent or not to a file and what's the incidence of this event. The most basic answer about the incidence is one's unique practice composition! If you're dealing with lots of older patients with chronic periodontal disease and old, broken down restorations, you will have thinner canals and more challenging cases. But I think the thing to aspire to is to see how often other people have difficulty reaching the apex (again, considering their practice composition!) In my humble opinion, and after having treated 20,000 cases during my time, if you have difficulty reaching the apex in more than 1 canal out of 10 canals (10%), then you're doing something wrong! I think that's a fairly conservative estimate. Most endodontists would say 5%. Today's ultrasonic technology and conceptual understanding of crown down and debris management can help dramatically reduce debris packing which is the main cause of apical blockage. More flexible NiTi instruments with safe tips can help negotiate fairly difficult curves nowadays. Again, as long as you're not short by more than 1mm in 90% of your cases then you're doing fine. If it's more frequent, you need more practice, preferably in extracted teeth. 
Good luck!