Importanceofpatencyinendodontics

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Importance of patency in endodontics
Article · January 2010
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ENDODONTOLOGY
Review Article
Importance of patency in endodontics
KHATAVKAR. ROHEET. A. *
HEGDE. VIVEK. S. **
ABSTRACT
Clinicians and researchers alike have tried to study the anatomy of the root canal system through various studies
and techniques. The focus is presently however on the apical anatomy and the means of shaping and obturating
the apex to provide an adequate seal. The complexity of the apical 3rd necessitates adequate access to the region;
hence maintenane of a patent apical foramen is essential. This article reviews the significance of patency and
patency filing in endodontics.
Key-words: Apical Patency, Apical Gauging.
One of the major controversies in root canal
file as a small flexible K-file, which is passively
concerns the apical limit of instrumentation and
moved through the apical constriction 0.5–1mm
obturation. A number of anatomical histological
beyond the minor diameter, without widening it.3
studies have been carried out to determine the true
Different concepts and formulas for
termination of the root canal1,2. The apical extent
determination of working lengths have been
of the cleaning and shaping procedure and also of
proposed, but the most widely accepted approach
the obturation material is a topic that has resulted
has been choosing a working length of 1 mm
in much controversy in endodontics. Patency filing
coronal to the root apex (compensating 0.5mm for
is a newer concept in endodontics which has been
the radiographic error and 0.5mm for the location
stressed by a number of authors and researchers.
of the CDJ from the radiographic terminus.)
This article discusses the concept of patency and
According to these concepts, the cemental canal
its necessity in endodontic therapy.
should not be instrumented. According to Weine’s
CONCEPT OF APICAL PATENCY
recommendations, the working length should be
Patency is defined in the American Association
1, 1.5 or 2 mm short of the radiographic terminus
of Endodontics’ glossary of terms as ‘a canal
depending upon the periapical status and alveolar
preparation technique where the apical portion of
bone surrounding the tooth.4 (Fig. 1)
the canal is maintained free of debris by
Radiography is a critical part of endodontics
recapitulation with a small file through the apical
but it should never be relied upon solely to
foramen’. Apical patency refers to the ability to pass
determine the apical extent of the root canal system.
a small No. 6-10 K-file through the apical foramen
In addition to radiography, feeling the apical
to assure that the canal is predictably negotiable.
constriction has also been recommended. However
In other words, patent. Buchanan defines a patency
* Post Graduate Student,** Professor & Head, Department of Conservative Dentistry and Endodontics, M.A.Rangoonwala Dental College, Pune.
87
ENDODONTOLOGY
KHATAVKAR. ROHEET. A., HEGDE. VIVEK. S.
root canals may have multiple apical constrictions
of the foramen as a result of the dentin debris
in which case it is difficult for the clinician to
formation during root canal therapy. This procedure
determine the apical extent of the cleaning and
does not imply the specific use of a 20 or 25 ISO
shaping procedure.
size file rather the use of smaller loose fitting files
like the ISO 08 or 10 is preferred. This procedure
The remaining length of the canal in most of
ensures a biologic cleansing of the apical most
the above cases is usually left uninstrumented
regions by allowing the flow of irrigants and finally
leaving 1-2 mm of the apical portion of the root
the obturation material (sealer)
canal with either intact pulp tissue or dentin debris
and microorganisms. According to Cohen and
The use of smaller diameter files results in
Burns5, 1 mm of a canal with a diameter of 0.25
virtually no contact of the instrument with the canal
mm, which is the diameter of narrower foramens,
walls. Hence the concept of ‘Apical Clearing’ or
provides enough space to lodge nearly 80,000
‘Clearing of the apical foramen’ was introduced.
streptococci.
This procedure involved determination of the
6
‘Working Width’ i.e. estimation of the file that binds
Hence the maintenance of the apical patency
at working length. Finally the file that binds slightly
is essential by performing patency filing. The
short of the final working length is use to
technique of patency filing involves passively
mechanically clean the area near the apical
inserting a small file, size 08 or 10, 2 mm beyond
foramen. This procedure aims at a mechanical
the established working length. No attempt is made
cleansing of the apical exit of the root canal and is
to instrument the foramen, merely to keep it open
a meticulous procedure. The use of a file to
or patent by deliberately loosening the debris
mechanically shape the apical region also
situated at the exit of the apical portal of exit7. One
precludes to formation of minute quantities of
approach to control accumulation of debris in the
apical region is the concept of apical patency.
apical debris; which may get pushed beyond the
3,8
apex.13
Endodontic literature has referred widely to
Use of patency filing has a number of
the concept of apical patency and a number of
advantages each of which will be discussed in detail:
clinicians and researchers have approved of this
1. Establishment and Maintenance of Glide
technique.9-12
path: Maintenance of a glide path means having a
Quite often the concept of ‘apical patency’
smooth preparation extending from the coronal to
has been misunderstood with ‘Apical Clearing’.
the apical which is reproducible by the successive
Because these two procedures are often
file used in the canal. Use of patency files ensures
misunderstood, it is essential to address the
removal of debris created by using the shaping files.
differences between them.
The use of a smaller file to or slightly beyond
Apical patency as mentioned merely refers to
working length frees up any debris and prevents
the passage of a small instrument beyond the
apical or lateral packing of debris against the canal
confines of the root in an effort to prevent blockage
wall.
88
ENDODONTOLOGY
IMPORTANCE OF PATENCY IN ENDODONTICS
2. Provides the clinician with knowledge of
system has been shown to have the most number
the anatomy of the apical root curvature:
of variations including presence of multiple portals
Following the preflaring of the coronal 3rd of the
of exit, apical deltas, laterally exiting canals, etc.15
root canal; the smaller files have an easy access to
(Fig.2) Also during routine cleaning shaping
the apical 3 of the root. Use of a pre-curved small
procedures the recommended enlargement of the
10 no. files allows the clinician to feel for and
apical exit of the canal i.e. the foramen i.e.
follow the curvatures in the apical 3rd of the canal.
restricted to a ISO size 25-30 no. This means there
This gives the clinician an early sense of the 3-
is lesser volume of irrigant in the apical 3rd of the
dimensional anatomy of the apical curves which
root canal system Patency filing ensures movement
may not always be seen through the radiograph
of the irrigant in these areas thus allowing enhances
Eg. The buccal curvature in the palatal root of the
irrigant interaction through cross-circulation of the
maxillary 1 molar (referred to as Bulls’ eye
irrigant solutions like alternate use 5.25% NaOCl
appearance on radiograph) or the distal curvatures
and 17% Liquid EDTA to clear both the organic as
of the maxillary lateral incisor
well as the inorganic components present in the
rd
st
debris. Buchanan has suggested using the patency
3. Facilitates Length Determination: Use of
file, prior to each irrigation, with the aim of
electronic apex locators is a common practice in
preventing possible organization of the debris,
modern endodontics. Apex locators provide an
which under irrigant pressure can become
accurate measurement of the apical portal of exit
compacted and form dentin plugs.3 Achieving
of the root canal. During their use for determining
patency in infected root canals also ensures efficient
the exact working length the operator can pass the
distribution of irrigant into lateral canals and apical
small 8 or 10 no. K-file slightly beyond the apex as
deltas.
indicated by the reading of the apex locator device.
This ensures two things, firstly establishment of the
5. Minimizes apical blockage and loss of
correct working length and secondly the
length: Forcing large instruments before they are
establishment of a patent apical foramen. If, during
indicated risks loss of patency by packing pulp,
the phase of canal measurement, a small instrument
dentinal shavings, and other canal contents (dentin
is inadvertently introduced beyond the apical
mud) into the narrowing cross sectional diameters
foramen to a depth of a few fractions of a millimetre,
of the root. Such “mud” compacted into the apical
no serious damage will result. However, injury will
third can be time consuming to bypass and nearly
occur if the entire biomechanical instrumentation
impossible to remove. Once created, blockages are
has been performed with an incorrect measurement
often the precursors of ledges, apical perforations,
of the working length. In this case, the patient may
transportations, and zips among other iatrogenic
continue to feel pain, and the canal will be filled
complications.
with exudates or blood.14
Achieving apical patency can be difficult, as
4. To improve the efficiency of irrigation at
canals may possess multiplanar curvatures and
the apical 3 level: The apical 3 of any root canal
significant calcification. Prevention of apical
rd
rd
89
ENDODONTOLOGY
KHATAVKAR. ROHEET. A., HEGDE. VIVEK. S.
blockage is paramount. It requires a determined
walls, without pushing them ahead of the
mental focus throughout the process from start to
instrument.
finish ensuring that you do everything possible to
8. Decreased Post-operative sensitivity: The
move pulp coronally out of the tooth. It is much
use of patency files ensures that the apical debris
easier to achieve and maintain patency than it is to
comprised of dentin shavings necrotic pulpal tissue
recapture it after a blockage. It is possible that the
and microorganisms are not pushed beyond the
use of a patency file would be important in some
cases
of
pulpless
teeth
with
confines of the root canal, into the periapical area.
bacterial
Simultaneous use of irrigants like sodium
contamination. Nevertheless, in cases of vital pulps,
hypochlorite and Aqueous EDTA ensures that all
many authors have postulated that preservation of
debris is eliminated by achieving patency. Apical
the vitality of the connective tissue localized in the
extrusion of infected debris to the periradicular
cemental portion of the root canal improves the
tissues is possibly one of the principal causes of
healing process and apical closure by deposition
post-operative pain Forcing microorganisms and
of neoformed cementum.16,17
their products into the periradicular tissues can
6. Reduced chances of Accidental errors:
generate an acute inflammatory response, whose
Iatrogenic accidents arising as a result of loss of
intensity will depend on the number and/ or
working length like canal transportation, ledge
virulence of the extruded microorganisms. Thus
formation, zipping, apical strip perforation can be
cleaning this debris through apical filing ensures a
avoided by achieving and maintaining patency at
decreased post-operative sensitivity.
all times during the course of endodontic treatment.
9. Mechanical disruption of Biofilms: Biofilms
As mentioned earlier Patency ensures a smooth
have become a well recognized phenomenon in
glide path to the apex which the successive
endodontics recently. Although not described in
instruments can follow for progressive enlargement
great detail, bacterial condensations on the walls
of the root canal wall.
7. Removal
of
of infected root canals have been observed
small
denticles
or
suggesting that mechanisms for biofilm formation
calcifications: A high number of cases requiring
may also exist inside the root canal space. 19, 20
root canal therapy present with calcifications which
Current research is highly focused on combating
have developed over a period of time; research
these biofilms for achieving a truly sterile
has shown that these denticles vary in size from
environment prior to obturation of the root canal
50ìm in diameter to several millimetres and may
space. Costerton has defined biofilms as highly
be present at any level of the canal wall the larger
organized structures consisting of bacterial cells
Use
enclosed in a self-produced exopolymeric matrix
of patency files ensures that the smaller diameter
attached on a surface.21 This matrix hinders the
files pass beyond the pulp stone and allow the
penetration of agents into the biofilm, limiting their
clinician to negotiate past the denticles, either
effectiveness to the superficial layer.22
ones may occupy the entire pulp chamber.
18
suspended in the tissue or attached to the canal
NaOCl in various concentrations has been
90
ENDODONTOLOGY
IMPORTANCE OF PATENCY IN ENDODONTICS
proven to be effective against planktonic bacteria.23,
be noted here that at all times the patency filing
A number of studies have also shown a high
technique will not influence the ‘tug back’ of the
antimicrobial activity of NaOCl against biofilm
master cone and not result in an over extrusion of
bacteria, particularly the more stubborn
the gutta percha cone. Failure to achieve a definite
Apical patency in
stop will however lead to over-extension of the
presence of NaOCl can also help in physical as
master cone resulting in a long term failure.(Fig 3.)
well as chemical disruption of the biofilms, thereby
Also in case patency filing has not been achieved
providing a predictable and precise level of chemo-
the operator would block himself out resulting in
mechanical debridement.
the obturating material ending shot of the anatomic
24
Enterococcus faecalis.
25, 26, 27
apex. (Fig.4)
10. Relieves apical pressure: Progression of
expansion of the periodontal ligament; further
LIMITATIONS IN ACHIEVING APICAL
PATENCY
leading to increased interstitial tissue pressure;
The following clinical instances could possibly
which can also cause physical pressure on the
prevent the clinician from achieving an adequate
nerve endings. This is clinically interpreted as pain
level of apical patency.
the periapical lesion generally results in an partial
on percussion. In addition noxious gases released
Firstly, the presence of an immature root as
as a result of degradation of the cellular debris also
seen in young individuals or a result of a trauma to
results in and increased apical pressure. 28, 29
the dentition during the development phase. In
Drainage and depressurization of this apical
such cases, the periapex is often directly exposed
pressure has been shown to relieve the pressure
to the periapical tissue resulting in frequent
and modify the local apical environment; to
bleeding during instrumentation and irrigation. Use
provide a favourable for the host defence
of irrigants delivered through side-vented needles;
mechanism to exert the repair process at the
and activation of the irrigant solution using either
periapex.30
manual or mechanical techniques is recommended
Similarly achieving apical patency helps in
for achieving better cleanliness of the canal space.31
relieving this apical pressure thereby allowing
Second condition that results in failure to
escape of gases and fluid from the periapex.
achieve apical patency is presence of blocked
11. Allows for obturation to apical foramen:
canals formed physiologically as a result of
The use of patency files will result in a smooth
deposition of cementum or as a host response to
passage of the obturating material within the
wall-off the bacterial ingress. In such cases use of
confines of the root canal and generally cause some
viscous chelating agents and use of pre-curved files
amount of sealer extrusion into the periapex. In
in a light pecking motion generally results in
case of thermoplasticized gutta percha obturation
negotiation of the canal. However a failure to clear
techniques, patency filing would clear the canal
the apical pathway may also imply a failure to
of most debris and generate sufficient hydraulics
effectively debride the apical region from groups
to seal most of the apical portals of exit. It should
of dormant microorganisms. In such cases, success
91
ENDODONTOLOGY
KHATAVKAR. ROHEET. A., HEGDE. VIVEK. S.
of the root canal therapy might be questionable
and regular follow-up of the case is required to
check for the progress and healing of the periapical
lesion. In cases of recurrence of clinical symptoms
or radiologic irreversible changes a surgical
approach might be warranted.
Figure 4.
A. Failure to negotiate canal and maintain apical patency resulted in
apical blockage and subsequent ‘short’ obturation.
B. Regaining lost length following removal of screw-post and
obturation material and achieving patency.
Post-obturation radiograph showing good apical and lateral
C. compaction with presence of apical puff indicating maintenance
of apical patency.
Figure 1. Weine’s recommendations for determining working length
based on radiographic evidence of root / bone resorption.
A. If no root or bone resorption is evident, the preparation should
terminate 1.0 mm from the apical foramen.
B. If bone resorption is apparent but no root resorption, shorten the
length by 1.5mm.
C. If both root and bone resorption is apparent, shorten the length
by 2.0mm.
CONCLUSION
If the use of patency files allows for the
prevention of many complications (apical blockage,
transportation, apical stripping, apical perforations)
allowing better irrigation in the apical 3rd and a
more effective means of chemo-mechanical
debridement of the apical 3rd of the root canal
system; then one must weigh the difference
Figure 2. Diagrammatic
Representation of variations in
the apical 3rd and location of the
apical constriction (From Harty’s
Endodontics in Clinical Practice
5th End. 2004).
between doing it judiciously or not. Understanding
the variability of foramen sizes, the bore of the
foramen should be discovered and sized
individually versus manufacturing it to a
preconceived size. This minimizes trauma to the
periapical tissues and consequently, respects the
apical region.
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