Significance of Apical
Third
Dr. Kapil Naladkar
Dr. Namrata Jidewar
Contents (part 2)
• Radiographic assessment of root apex
• Termination point for root canal procedure
• Challenges faced due to apical third anatomy during endodontic
procedures
• Conclusion
• References
Radiographic Assessment of Apical Third
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 , Issue 3 Quintessence
Publishing: Journals: ENDO/
Radiographs
• Walton(1973) introduced an important refinement in dental radiographs and helped in
visualising the third dimensions by varying the horizontal angulation.
• This method helps to separate overlying canals.
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 ,
Issue 3 Quintessence Publishing: Journals: ENDO/
Radiographs
• To confirm, a 2nd radiograph exposed from mesial/distal angulation of 10-
30degrees
• Shows vertical lines indicating peripheries of additional root surfaces.
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 , Issue 3 Quintessence Publishing: Journals: ENDO/
Radiopaque contrast media
• Lateral canals are usually not detected on intraoral radiographs, and in some instances
can only be observed after obturation with radiopaque material.
• Scarfe et al used Hypaque (Ruddle, Santa Barbara, CA, USA) to detect accessory canals.
William C. Scarfe, Charles R. Fana, Allan G. Farman,Radiographic detection of accessory/lateral canals: Use of RadioVisioGraphy and
hypaque,Journal of Endodontics,Volume 21, Issue 4,1995
Shearer AC, Wasti F, Wilson NH. The use of a radiopaque contrast medium in endodontic radiography. Int Endod J.
1996 Mar;29(2):95-8..
Digital radiography
• Mouyen developed radiovisiography in 1970. The newer digital systems rely on
electronic detection of an x-ray generated image that is processed and reproduced on a
computer screen.
• Radio visiography (RVG) is also known as direct digital radiography (DDR)
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 , Issue 3 Quintessence Publishing:
Journals: ENDO/
• Simone et al used RVG to determine the incidence of root canal bifurcation in mandibular
incisors.
• The digital radiography showed the presence of bifurcation of root canals in 20% of teeth
evaluated in vitro in the mesiodistal direction. In the buccolingual direction, 17.5% of teeth
evaluated in vivo and 15% evaluated in vitro presented bifurcation.
• This technology offers a multitude of options for improving the visual quality of diagnostic
images with appropriate enhancement techniques such as magnification and reverse contrast.
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 , Issue 3
Quintessence Publishing: Journals: ENDO/
de Oliveira SH, de Moraes LC, Faig-Leite H, Camargo SE, Camargo CH. In vitro incidence of root canal bifurcation in
mandibular incisors by radiovisiography. J Appl Oral Sci. 2009 May-Jun;17(3):234-9..
Computed tomography (CT)
• Tachibana and Matsumato were first to suggest the use of tomography to study the root canal
system in 1990, but as a result of the poor resolution of conventional medical CT scans they were
not able to study the root canals in detail.
• Cone beam computed tomography (CBCT) or digital volume tomography (DVT), which uses an
extraoral imaging scanner to produce 3D scans, has become available for dental practice owing
to reduced cost and dimensions.
Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall 2012Volume 6 , Issue 3 Quintessence
Publishing: Journals: ENDO/
Eduarda Helena et al Ex Vivo Detection of Apical Delta in Premolars: A
Comparative Study Using Periapical Radiography, Cone-beam Computed
Tomography, and Micro–computed Tomography,Journal of Endodontics,
Volume 45, Issue 5,2019,Pages 549-553
Nyan M. Aung, Kyaw
K. Myint, "Diagnostic
Accuracy of CBCT for
Detection of Second
Canal of Permanent
Teeth: A Systematic
Review and Meta-
Analysis", Internationa
l Journal of Dentistry,
vol. 2021
Termination point for root canal procedures
• The issues of working length determination, its apical extent, and the position of the
final root canal filling have been controversial, as differing points of view have existed
between the biologically based and clinically based endodontists regarding this concept
for decades.
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based endod 1, 4
(2016).
Forcing of tannic acid into remaining pulp where accessibility was the problem, where it forms an
albuminate of tannin; a compound which is insoluble in any of the fluids of the surrounding tissues
and consequently no disintegration can take place to cause any after trouble. (Mills 1897)
Recognizing the fact that there were significant apical ramifications led dentists to performing
many procedures that only resulted in the removal of one half to two thirds of the dental pulp
(partial pulpectomy) (Davis 1923)
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based
endod 1, 4 (2016).
• Dr. Rhein (1920)advocated filling beyond the end of
the root so the filling material would encapsulate the
apical 2–3 mm.
• Thereby sealing off all the accessory communications.
He referred to this as “mortarization” of the root end.
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based
endod 1, 4 (2016).
• Once a piece of foreign material has penetrated through the foramen, no favorable condition
of any kind can induce the closure of the entrance by the formation of a hard wall. (Gottlieb
et al. 1950)
• In 1953, an article was published by Bernard Berg that served as the basis for new concepts
in root canal preparation that focused on the importance of canal shaping along with
thorough obturation to the root apex (Berg 1953).
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based
endod 1, 4 (2016).
• First International Endodontic Conference that occurred in Philadelphia, PA, USA, in
1953.
• Two very specific guidelines originated from the presentations and deliberations from a
multitude of international experts, in particular Drs. Louis I. Grossman and Lester B.
Cahn.
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based endod 1, 4
(2016).
• These two principles were as follows:
• 1. Traumatic injury to the surrounding (periapical) soft tissue should be avoided at all times. For
this, instrument stops should be used and instruments should be confined entirely within the root
canal (Grossman 1953).
• 2. “The canal filling should seal the apical foramen, and that if the apical millimeter or so of the
canal is filled with healthy living tissue, the root canal filling should terminate at this level rather
than at the apical foramen” (Grossman 1953).
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-
based endod 1, 4 (2016).
• The wise old suggestion to slightly underextend root canal fillings in case of vital extirpation and
to fill to the radiographic apex or slightly beyond in cases of pulpal necrosis and gangrene is
probably more meaningful in terms of patient comfort that in terms of the ultimate result.
(Schilder 1974)
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-
based endod 1, 4 (2016).
• Contemporarily, following philosophies tend to permeate the clinical world of endodontics
regarding where to terminate the obturation:
• (1) those based strictly on the anatomical studies
• (2) those based strictly on prognostic studies and outcomes of treatment
• (3) those based on empirical directives
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or
disambiguation?. Evid.-based endod 1, 4 (2016).
Those based strictly on the anatomical studies
• It is impossible to instrument accessory canal ramifications and that, when these
ramifications appeared filled on the radiograph, it was only due to the forcing of root
canal sealer into the tissues located in these ramifications, which was verified by
(Ricucci & Siqueira 2010)
• Ricucci and Langeland performed histological analysis of teeth that had been root canal
treated and extracted after different observation periods (Ricucci & Langeland 1998).
• They found that the most favorable histological conditions occurred when
instrumentation and obturation remained at or short of the apical constriction, whether the
pulp had been vital or necrotic, and even if some bacteria were present in the periapical
tissues.
• When the sealer and/or gutta-percha was extruded into the periapical tissues, the lateral
canals and the apical ramifications, there was always a severe inflammatory reaction
including a foreign body reaction despite the absence of pain. (Ricucci & Langeland
1998)
Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation. Part 2. A histological study. Int
Endod J. 1998;31:394–409
Ricucci D, Langeland K. Apical limit of
root canal instrumentation and
obturation. Part 2. A histological study.
Int Endod J. 1998;31:394–409
Prognostic studies and treatment outcomes
• The optimal result was to end the root filling one to two mm inside the radiographic
apex - exactly the same recommendation that emerged from the anatomical studies (in
the early 1900s).
• In 2000, Wu and co-workers did an extensive evaluation of studies over the previous
50 years and arrived at the following conclusion (Wu et al. 2000):
• After vital pulpectomy- 2 to 3 mm short of the radiographic apex
• With pulpal necrosis- at or within 2 mm of the radiographic apex (0 to 2 mm)
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based endod 1,
4 (2016).
• If the root fillings were short of the apex, a lower success rate of 57 %-95 % was found, If
extrusion of root-filling material in periapical tissues were found, the success rate was ever
lower at 50 %-90 %. (Kirkevang & Bindslev 2002) (Schaeffer et al. 2005)
Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-
based endod 1, 4 (2016).
• While clinically desirable by many to see these puffs or buttons of sealer radiographically,
Ricucci and Siquiera (Ricucci & Siqueira 2010) found that
“vital tissue in the accessory communications was not removed during canal shaping and
cleaning and although lateral canals appeared radiographically filled they were actually not
obturated, and the remaining tissue in the ramification was inflamed and enmeshed with the
filling material”(Ricucci & Siqueira 2010)
• Most recently, Azim and associates reviewed radiographically root-treated teeth
of a mean follow-up period of 2 years (Azim et al. 2016).
• Roots instrumented apically within 0.5 mm from the radiographic apex had a
significantly more favorable outcome (88 %).
• Those >2 mm short from the radiographic apex had the least favorable outcome
(33 %). Teeth with overextended root fillings showed delayed healing by almost
14 months.
Azim AA, Griggs JA, Huang GT. The Tennessee study: factors affecting treatment outcome and healing time following
nonsurgical root canal treatment. Int Endod J. 2016 Jan;49(1):6-.
Empirical directives
• If the dental pulp is vital (inflamed; irreversible pulpitis), attempts are made to retain all
procedures within the root canal. While this position has been advocated as approximately 0.5–
1.0 mm from the radiographic apex, this dictate is flawed (Ricucci 1998).
• In essence, the thought behind this approach is that the tissue that invaginates into the canal
from the periodontal ligament, and which is periodontal in nature, is not disturbed by the
subsequent manipulations that are performed within these confines.
• non-vital (obvious necrosis; presence of a periapical radiolucency)
• Here also, a middle-of-the-road philosophy has been proposed, that is, cleaning and shaping
the canal to the entire length of the root and then backing up or retreating into the canal
sufficiently to develop a constriction or stop inside of the root where the dentin terminates for
further intracanal procedures (Simon 1994).
• However, even with this choice, the movement of materials past the root apex into the
periapical tissues usually cannot be prevented.
Working length determination
• The endodontic glossary defines working length as “the distance from a coronal reference
point to a point at which the canal preparation and obturation should terminate”.
• During 19th century, working length was usually calculated by placing the instrument in the
canal and the point where the patient felt pain was recorded.
• In 1901, Dr. Weston A. Price noticed incomplete root canal fillings as evidenced in
radiographs and suggested that radiographs should be used to check the accuracy of the root
canal fillings.
Bhatt, Akanksha & Gupta, Vishesh & Rajkumar, B. & Arora, Ruchi. (2015). WORKING LENGTH DETERMINATION-THE SOUL OF ROOT
CANAL THERAPY: A REVIEW. 02. International Journal of Dental and Health Sciences Review Article Volume 02,Issue 01 105-115.
Methods for working length determination
• 1. Grossman’s Method
• 2. Ingle’s Method
• 3. Kuttler Method
Radiographic • 4. Best’s Method
methods • 5. Bregman’s Method
• 6. Bramante’s Method
• 7. X-ray Grid System
• 8. Xero Radiography
• 9. Direct Digital Radiography
• 1. Apex Finder
Non radiographic • 2. Audiometric Method
methods • 3. Tactile Method
• 4. Paper Point Evaluation Method
• 5. Electronic Apex Locators.
Radiographic method
• Grossman’s method
• The original diagnostic radiograph is used to estimate the working length of the tooth
from occlusal to root apex.
• This length is later verified by placing instruments to the estimated working length in
the root canal and taking an instrumentation radiograph.
Bhatt, Akanksha & Gupta, Vishesh & Rajkumar, B. & Arora, Ruchi. (2015). WORKING LENGTH DETERMINATION-THE SOUL OF ROOT CANAL
THERAPY: A REVIEW. 02. International Journal of Dental and Health Sciences Review Article Volume 02,Issue 01 105-115.
• A radiograph is taken to compare the exact position of the instrument in the root canal with
the measure depth of insertion.
• If necessary the measured length is adjusted so that the instrument tip is inserted up to 0.5
mm from the apical exit of the root canal to the reference point on the crown of the tooth.
• If the K-file is 1 mm longer or shorter of the radiographic foramen one should add or
subtract the necessary length to obtain the root canal length, but if the differences are
greater than 1 mm, one should make necessary adjustments on the file and take another
radiograph.
• Actual length of tooth = ALI x RLT/ RLI
• ALT -Actual length of tooth
• ALI -Actual length of instrument
• RLT -Radiographic length of tooth
• RLI -Radiographic length of instrument
Non radiographic method
• 1. Apex finder
• M.M.Negm in 1982 introduced a novel method of determining the length of root
canal without the use of radiographs. The new instrument apex finder is used to
locate the apex as well as measuring the root length.
• The application of this method is based on insertion of a fine plastic tapered
bared shaft through a beveled tube into the root canal.
• When resistance to withdrawl is felt which indicates that some barbs have
engaged the apical margin, the shaft is marked at the level of the cusp tip.
• The distance between the mark and the barbs, which caused the resistance, is
measured.
• Paper point evaluation
• The paper point may be used to detect bleeding or apical moisture.
• A bloody or moist tip suggests an over extended preparation. Further assessment of
the apical preparation and working length should be made. The point of wetness
often given an approximate location to the actual canal end point.
Bhatt, Akanksha & Gupta, Vishesh & Rajkumar, B. & Arora, Ruchi. (2015). WORKING LENGTH DETERMINATION-THE SOUL OF ROOT CANAL
THERAPY: A REVIEW. 02. International Journal of Dental and Health Sciences Review Article Volume 02,Issue 01 105-115.
• Electronic apex locator
• These devices attempt to locate the apical constriction, the cemento-dentinal
junction, or the apical foramen. They are not capable of routinely locating the
radiographic apex.
• In 1918, Custer was the first to report the use of electric current to calculate
working length.
Bhatt, Akanksha & Gupta, Vishesh & Rajkumar, B. & Arora, Ruchi. (2015). WORKING LENGTH DETERMINATION-THE SOUL OF ROOT CANAL THERAPY: A
REVIEW. 02. International Journal of Dental and Health Sciences Review Article Volume 02,Issue 01 105-115.
• The scientific basis for apex locators originated with research conducted by Suzuki in
1942.
• All apex locators function by using the human body to complete an electrical circuit.
One side of the apex locator’s circuitry is connected to an endodontic instrument.
• The other side is connected to the patient’s body either by a contact to the
patient’s hand.
• The electrical circuit is completed when the endodontic instrument is advanced
apically inside the root canal until it touches periodontal tissue.
Challenges faced due to apical third
anatomy during endodontic procedures
Apical size preparation
• The initial file chosen for exploring the canal anatomy and for binding in canal is used
as a measure of apical diameter.
• Some authors suggest a larger apical preparation than previously used to disinfect or
clean the apical portion. A larger apical preparation allows better penetration of
irrigants.(Le OY et al, 2019)
• However, others argue that it removes unnecessary dentin walls and may weaken the
root canal system.(Zelic k et al,2015)
Hindlekar, A., Kashikar, R., Qaiser, S., Gupta, S., & Patil, R. S. (2022). Apical third and its significance. International Journal of Health Sciences,
6(S4), 3452–3458.
Butcher, Seth, Abeer Mansour,
and Mohamed Ibrahim.
"Influence of apical preparation
size on effective conventional
irrigation in the apical third: a
scanning electron microscopic
study." European Endodontic
Journal 4.1 (2019): 9.
Fatima S, Kumar A, Andrabi SMUN, Mishra SK, Tewari RK. Effect of Apical
Third Enlargement to Different Preparation Sizes and Tapers on Postoperative
Pain and Outcome of Primary Endodontic Treatment: A Prospective
Randomized Clinical Trial. J Endod. 2021 Sep;47(9):1345-1351.
Denticles and dystrophic mineralisation
• Seltzer et.al. 1966 found dystrophic mineralisation in the apical pulp tissue of
approximately 25% of anterior teeth.
• Pulp stones are nodular calcified masses appearing in either or both the coronal
or root portions of the pulp organ comprised of tubular dentin and alveolar
mineralized material.
• Normally found as – attached, embedded, adherent (only part of it is attached to
the dentin).
Hindlekar, A., Kashikar, R., Qaiser, S., Gupta, S., & Patil, R. S. (2022). Apical third and its significance. International
Journal of Health Sciences, 6(S4), 3452–3458.
• Diffuse calcifications can generally be observed in root canals of older adults, but
they may also be present in the pulp chamber of younger patients affected by
caries.
• Instruments with reduced flute can also be used, such as a Canal Pathfinder (JS
Dental, Ridgefield. Conn) or instruments with greater shaft strength such as the
Pathfinder CS (Kerr Manufacturing Co.), which are more likely to penetrate
highly calcified canals.
• C+Files (Denstply, Tulsa, OK, USA) are also ideal for initial instrumentation of
calcified root canals.
Dhinesh Kumar, S. Delphine Priscilla Antony. Calcified Canal and Negotiation-A Review. Research J. Pharm. and Tech
2018; 11(8): 3727-3730.
• Coronal flaring in a crown-down fashion is preferred. Incremental instrumentation is
achieved by creating new increments between the established widths by cutting off a
portion of the file tip, thus making it slightly wider in diameter.
• In extremely sclerotic canals, only 0.5 mm segments are trimmed, increasing the
instrument width by 0.01mm and making a size 10 into a size 11, etc. because cutting
the shaft imparts a flat tip, a metal nail file is used to smooth the end and reestablish a
bevel after the removal of any segment.
Dhinesh Kumar, S. Delphine Priscilla Antony. Calcified Canal and Negotiation-A Review.
Research J. Pharm. and Tech 2018; 11(8): 3727-3730.
Shabaan, A., Hassanien, E., & Elsewify, T. (2021). Endodontic guides and ultrasonic tips for management of
calcifications. Giornale Italiano Di Endodonzia, 35(2)
Apical resorption
• Shallow resorption of the dentin in the apical portion of the root
canal are normal occurrence: Causes of apical resorption
• 1. Orthodontic treatment.
• 2. Accident / trauma.
• 3. Surface resorption
• 4. Inflammatory resorption.
• 5. Replacement resorption
Hindlekar, A., Kashikar, R., Qaiser, S., Gupta, S., & Patil, R. S. (2022). Apical third and its significance.
International Journal of Health Sciences, 6(S4), 3452–3458.
• In any event if apical resorption has taken place, the position of apical foramen
and apical constriction would change accordingly and thus the working length
measurement also.
• According to “weine” If there is no resorption of root end or bone then shorten the
length by the Standard 1mm.
• If periapical bone resorption is apparent then shorten by 1.5mm.If both root and
bone resorption are apparent then shorten by 2mm.
Irrigation
• The ability of an irigant to be distributed to the apical portion depends on canal
anatomy, size of instrumentation and mode of delivery system.
• Excess pressure into canals during irrigation should be avoided to prevent extrusion
of irrigant into periapical tissues,it is strongly recommended that needle lie passively
in the canal and not engage the walls.
• Other important factor is volume of irrigant and irrigating needle although larger
gauge needle allow irrigant to be flushed and replenish more quickly, the wider needle
diameter does not allow cleaning of apical and narrower areas of root canal system.
Hindlekar, A., Kashikar, R., Qaiser, S., Gupta, S., & Patil, R. S. (2022). Apical third and its significance.
International Journal of Health Sciences, 6(S4), 3452–3458.
Vemuri S, Kolanu SK, Varri S, Pabbati RK,
Penumaka R, Bolla N. Effect of different final
irrigating solutions on smear layer removal in
apical third of root canal: A scanning electron
microscope study. J Conserv Dent. 2016;19(1):87-
90.
Solete, Pradeep, et al. "Effect of Various
Irrigant Activation Methods and Its
Penetration in the Apical Third of Root
Canal—In Vitro Study." European Journal
of Dentistry 17.01 (2022): 057-061.
Bakthavatchalam B, Ranjani MS, Amudhalakshmi K,
Dhanalakshmi S. Comparative evaluation of canal cleanliness at
apical third using Self-Adjusting File and Wave One File with
different irrigants: an in vitro scanning electron microscopic
study. Med Pharm Rep. 2023 Jan;96(1):79-85
CONCLUSION:
• Keeping the apical constriction at its original position and size has great
value for the prevention of iatrogenic events, facilitating excellence in
irrigation, instrumentation, and obturation, and providing the best possible
clinical result.
REFERENCES
• 1Bakthavatchalam B, Ranjani MS, Amudhalakshmi K, Dhanalakshmi S. Comparative evaluation of
canal cleanliness at apical third using Self-Adjusting File and Wave One File with different irrigants:
an in vitro scanning electron microscopic study. Med Pharm Rep. 2023 Jan;96(1):79-85
• Solete, Pradeep, et al. "Effect of Various Irrigant Activation Methods and Its Penetration in the
Apical Third of Root Canal—In Vitro Study." European Journal of Dentistry 17.01 (2022): 057-061.
• Vemuri S, Kolanu SK, Varri S, Pabbati RK, Penumaka R, Bolla N. Effect of different final irrigating
solutions on smear layer removal in apical third of root canal: A scanning electron microscope
study. J Conserv Dent. 2016;19(1):87-90.
• Hindlekar, A., Kashikar, R., Qaiser, S., Gupta, S., & Patil, R. S. (2022). Apical third and its
significance. International Journal of Health Sciences, 6(S4), 3452–3458.
• Shabaan, A., Hassanien, E., & Elsewify, T. (2021). Endodontic guides and ultrasonic tips for
management of calcifications. Giornale Italiano Di Endodonzia, 35(2)
• Dhinesh Kumar, S. Delphine Priscilla Antony. Calcified Canal and Negotiation-A Review. Research
J. Pharm. and Tech 2018; 11(8): 3727-3730.
• Fatima S, Kumar A, Andrabi SMUN, Mishra SK, Tewari RK. Effect of Apical Third
Enlargement to Different Preparation Sizes and Tapers on Postoperative Pain and
Outcome of Primary Endodontic Treatment: A Prospective Randomized Clinical Trial. J
Endod. 2021 Sep;47(9):1345-1351.
• Butcher, Seth, Abeer Mansour, and Mohamed Ibrahim. "Influence of apical
preparation size on effective conventional irrigation in the apical third: a scanning
electron microscopic study." European Endodontic Journal 4.1 (2019): 9.
• Methods to study root canal morphology: A review Grover, Charu / Shetty, Neeta Fall
2012Volume 6 , Issue 3 Quintessence Publishing: Journals: ENDO/
• William C. Scarfe, Charles R. Fana, Allan G. Farman,Radiographic detection of
accessory/lateral canals: Use of RadioVisioGraphy and hypaque,Journal of
Endodontics,Volume 21, Issue 4,1995
• Shearer AC, Wasti F, Wilson NH. The use of a radiopaque contrast medium in endodontic radiography. Int
Endod J. 1996 Mar;29(2):95-8..
• de Oliveira SH, de Moraes LC, Faig-Leite H, Camargo SE, Camargo CH. In vitro incidence of root canal
bifurcation in mandibular incisors by radiovisiography. J Appl Oral Sci. 2009 May-Jun;17(3):234-9..
• Eduarda Helena et al Ex Vivo Detection of Apical Delta in Premolars: A Comparative Study Using
Periapical Radiography, Cone-beam Computed Tomography, and Micro–computed
Tomography,Journal of Endodontics,
• Nyan M. Aung, Kyaw K. Myint, "Diagnostic Accuracy of CBCT for Detection of Second Canal of
Permanent Teeth: A Systematic Review and Meta-Analysis", International Journal of Dentistry, vol. 2021
• Gutmann, J.L. Apical termination of root canal procedures—ambiguity or disambiguation?. Evid.-based
endod 1, 4 (2016).
• Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation. Part 2. A
histological study. Int Endod J. 1998;31:394–409
• Thank you
