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Apical limit of root canal instrumentation and obturation,part 2. A histological studyD. RI CUCCIa&K. L ANGE L ANDbaPrivate practice, Cetraro (CS), Italy;bDepartment of Restorative Dentistry and Endodontology, School of Dental Medicine,University of Connecticut, CT, USASummaryTheresults of aninvivohistological studyinvolvingapical and periapical tissues following root canaltherapy after different observation periodsdemonstrated the most favourable histologicalconditions whentheinstrumentationandobturationremainedat or short of theapical constriction. Thiswasthecaseinthepresenceofvitalornecroticpulps,alsowhenbacteriahadpenetratedtheforamenandwerepresent in the periapicaltissues.When thesealerand/or the gutta-percha was extruded into theperiapical tissue, the lateral canals and the apicalramifications, therewasalwaysasevereinflammatoryreactionincluding a foreignbody reactiondespite aclinical absence of pain.Keywords: apical limit, rootcanal instrumentation/obturation, tissue reactions.IntroductionThefirstscientificbasisformodernclinicalEndodontologywas established by Davis (1922). He was the first tosuggest that careful treatment of theapical tissuewas arequirement for success in root canal treatment.Since thenmanyhistological studies, basedonapicalbiopsies including the surrounding periapical tissues, orendodontically treated teeth which were extracted atvaryingperiods oftime,confirmed hisobservation(Hattonetal. 1928, Blayney 1929, Nygaard-O/stby 193944,Laws 1962, Nyborg & Tullin 1965, Engstrom &Spa ngberg1967, Seltzeretal. 1968and1969). All thesestudies agreed that, in vital pulp treatment, partialpulpectomy was preferred to total pulp removal.Langeland(1957, 1967, 1976, 1981, 1987and1995),Linetal. (1984)describedindetail theprogressionof thepulpnecrosisanddemonstratedthatvitalpulptissuewithnervesandvesselsremaininthemost apical part of themain canal even in the presence of a large periapicallesion. Asalogical clinical consequenceof theseobserva-tions, they suggested terminating instrumentation andobturation at the apical constriction, just short of theradiographic apex, eveninthe presence of a periapicallesion. Theyalsoconcludedthat, intime, all pulptissuewill beinvolvedbynecrosis, finallyincludingapical tissueandthetissuecontainedintheramifications,andbacteriawill establishthemselvesintheperiapical lesionasfarasthe necrosis occurs (Pasconetal. 1987, Oguntebi etal.1982,Linetal.1996).Eveninthisextremesituation,themost appropriate level in limiting the endodonticoperationis still theapical constriction: thearealocatedinside the root canal (Langeland 1995).Thepurposeofthepresentstudywastoinvestigatethehistopathologicalresponseoftheintracanalpulptissue,ofthepulptissuecontainedinthelateral canals, theapicalramifications, and of periapical tissues to endodonticprocedureswhenperformedshortof orbeyondtheapicalconstriction, in both vital and necrotic pulp conditions.Materials and methodsTheexperimentalmaterialconsistedof41humanteeth,atotalof49roots,obtainedfrom36patients(14males,22females) aged 1665years. All human subjects who parti-cipated in the experimental investigation gave theirinformedconsent after the nature of the procedure andpossible discomforts and risks had been fully explained(Table1).Ten of these cases (nine teeth) came from a previous in-vestigation(Ricucci etal. 1990) consistingof biopsies ofthe apex and periapical bone following instrumentationandCa(OH)2medication(cases110).Nineteenteethhadbeen exposed to cariesand/or operative damage, requiringendodontic treatment for pulpal/periapical involvement(cases 1129).394 q1998BlackwellScienceLtdInternational Endodontic Journal (1998) 31, 394409Correspondence: Dr Domenico Ricucci Piazza Calvario 7, I-87022Cetraro (CS), Italy (e-mail:ricucci@fr.antares.it).Table1CaseNumberPatientSexAge&Tooth/RootPathologyDiagnosisP.a.lesionMedicationDurationmedication(days)ProceduresApicallevelprocedures(mmfromrad.apex)Obser-vationperiodP.a.lesionatthemomentofthebiopsyClinical/radio-logicalevaluationofthetreatmentBiopsy1APM1814/PalatalrootNoneVitalNoCa(OH)27Instrumentationonly1:57daysNo--Extraction2APM1814/BuccalrootNoneVitalNoCa(OH)27Instrumentationonly1:57daysNo--Apical/P.a.biopsy3GVM4812FractureNecroticYesCa(OH)215Instrumentationonly115daysYes--Apical/P.a.biopsy4RMF1814/BuccalrootCariesNecroticNoCa(OH)235Instrumentationonly135daysNo--Apical/P.a.biopsy5MSF5711CariesNecroticYesCa(OH)27Instrumentationonly1:57daysYes--ApicalP.a.biopsy6AIRM5412Iatrogenesis(prostheticpreparation)NectroticYesCa(OH)215Instrumentationonly1:515daysYes--Apical/P.a.biopsy7PSF5511CariesVitalYesCa(OH)214Instrumentationonly114daysYes--Apical/P.a.biopsy8PSF5521CariesVitalNoCa(OH)214Instrumentationonly114daysNo--Apical/P.a.biopsy9SCF3421CariesVitalNoCa(OH)221Instrumentationonly1:521daysNo--Apical/P.a.biopsy10ERM1911NoneVitalNoCa(OH)282Instrumentationonly1:582daysNo--Apical/P.a.biopsy11EAF3011CariesVitalNoCresatin7Instrumentationonly1:57daysNo--Apical/P.a.biopsy12FRM1912Iatrogenesis(pulpcapping)NecroticYesCa(OH)227Completeendotreatment1:548daysYes--Apical/P.a.biopsy13PAM2211CariesNecroticYesCa(OH)27Completeendotreatment1:548daysYes--Apical/P.a.biopsy14MTSF1821Iatrogenesis(Pulpcapping)NecroticYesNo--Completeendotreatment1:53yearsNoSuccessfulApical/P.a.biopsy15MIF2312CariesNecroticYesNo--CompleteendotreatmentBeyondapex6yearsYesDoubtfulApical/P.a.biopsy16SPF2414/BuccalrootCariesNecroticYesCa(OH)220Completeendotreatment25monthsYesDoubtfulApical/P.a.biopsy17SAF4422CariesNecroticYesCresatin7CompleteendotreatmentBeyondapex13monthsYesDoubtfulApical/P.a.biopsy18LAM3721CariesVitalNoNo--CompleteendotreatmentBeyondapex4monthsYesFailureApical/P.a.biopsyRTC instrumentation and obturation 395q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 394409Table1Continued.CaseNumberPatientSexAge&Tooth/RootPathologyDiagnosisP.a.lesionMedicationDurationmedication(days)ProceduresApicallevelprocedures(mmfromrad.apex)Obser-vationperiodP.a.lesionatthemomentofthebiopsyClinical/radio-logicalevaluationofthetreatmentBiopsy19EPM3122CariesVitalNoNo--Completeendotreatment1:582daysNo--Apical/P.a.biopsy20EPM3124/BuccalrootCariesVitalNoNo--Completeendotreatment1:562daysNo--Apical/P.a.biopsy21FMM4222CariesNecroticYesCa(OH)210Completeendotreatment1:518daysYes--Apical/P.a.biopsy22DOF2321ExternalrootresorptionVitalNoCa(OH)27Completeendotreatment1&1yearYesFailureApical/P.a.biopsy23RSM3944CariesNecroticYesCa(OH)27Completeendotreatment14monthsYes--Apical/P.a.biopsy24GCF2023CariesNecroticYesNo--Completeendotreatment11yearYesFailureApical/P.a.biopsy25GSM2211CariesNecroticYesNo--Completeendotreatment14yearsYesFailureApical/P.a.biopsy26MGF1822CariesNecroticYesNo--Completeendotreatment0:54yearsYesFailureApical/P.a.biopsy27VVM6221CariesNecroticYesCa(OH)221Completeendotreatment140daysYes--Apical/P.a.biopsy28LVM6512CariesNecroticYesCa(OH)214Completeendotreatment135daysYes--Apical/P.a.biopsy29SZF2121CariesNecroticNoCresatin7Completeendotreatment1:510yearsand8monthsYesFailureApical/P.a.biopsy30MIM2535CariesVitalNoNo--Completeendotreatment26yearsNoSuccessfulExtraction31MFF4312CariesVitalNoNo--Completeendotreatment22yearsNoSuccessfulExtraction32ACF3127/mesialrootCariesVitalNoCresatin7Completeendotreatment1:55yearsNoSuccessfulExtraction33ACF3127/palatalrootCariesVitalNoCresatin7Completeendotreatment25yearsNoSuccessfulExtraction34ACF3127/distalrootCariesVitalNoCresatin7Completeendotreatment25yearsNoSuccessfulExtraction35APF4712Iatrogenesis(Prostheticpreparation)NecroticYesCa(OH)29Completeendotreatment13yearsNoSuccessfulExtraction36AMSF3915Iatrogenesis(Pulpcapping)NecroticYesCa(OH)217Completeendotreatment15monthsNoSuccessfulExtractionq 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 394409396 D. Ricucci & K. LangelandTable1Continued.CaseNumberPatientSexAge&Tooth/RootPathologyDiagnosisP.a.lesionMedicationDurationmedication(days)ProceduresApicallevelprocedures(mmfromrad.apex)Obser-vationperiodP.a.lesionatthemomentofthebiopsyClinical/radio-logicalevaluationofthetreatmentBiopsy37FLF1635CariesVitalYesNo--Completeendotreatment1:53yearsand1monthNoSuccessfulExtraction38ALF2646/mesialrootCariesVitalNoNo--Completeendotreatment1:57yearsand3monthsNoSuccessfulExtraction39ALF2646/distalrootCariesVitalNoNo--Completeendotreatment1:57yearsand3monthsNoSuccessfulExtraction40EPM2345CariesNecroticYesNo--CompleteendotreatmentBeyondapex6yearsand6monthsNoDoubtfulExtraction41GAF4523CariesVitalNoNo--Completeendotreatment25yearsand4monthsNoSuccessfulExtraction42AMF3126/mesialrootCariesVitalNoCa(OH)27CompleteendotreatmentBeyondapex3yearsand5monthsNoSuccessfulExtraction43AMF3126/palatalrootCariesVitalNoCa(OH)27Completeendotreatment1:53yearsand5monthsNoSuccessfulExtraction44AMF3126/distalrootCariesVitalNoCa(OH)27Completeendotreatment13yearsand5monthsNoSuccessfulExtraction45VVM6246/mesialrootCaries/PerioNecroticYesCresatin7Completeendotreatment1:57yearsNoSuccessfulExtraction46VVM6246/distalrootCaries/PerioNecroticYesCresatin7Completeendotreatment1:57yearsNoSuccessfulExtraction47VVM6236/mesialrootCariesNecroticYesCa(OH)27Completeendotreatment1:56yearsand7monthsNoSuccessfulExtraction48VVM6236/mesialrootCariesNecroticYesCa(OH)27Completeendotreatment0:56yearsand7monthsNoSuccessfulExtraction49APF5533Caries/PerioVitalNoCa(OH)27Completeendotreatment11yearNoSuccessfulExtraction&Theageofthepatientisintendedatthemomentoftheendodontictreatment.&Theobturationwas1mmshortoftheradiographicapex.Actually,inthehistologicsectionsitprotrudedintotheperiapicaltissuefromananticipatedforamen.q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 394409RTC instrumentation and obturation 397Endodontic therapy was performed by the sameoperator, using the same technique. In all casesprophylaxis, local anaesthesia, rubber damapplication,disinfectionof the fieldwith30%H2O2followedby5%tinctureof iodinewereperformed(Mo ller 1966). Duringinstrumentationcopiousamountsof1%NaOClwereusedfollowed by thorough aspiration. The canals wereobturated

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