Introduction: Endodontic infections are polymicrobial in nature. Enterococcus fecalis is the most common micro-organism isolated from failed endodontic cases. The constant increase in antibiotic resistant strains and side effects caused by synthetic drugs has prompted researchers to look for herbal alternatives since the gold standard for irrigation i.e., sodium hypochlorite (NaOCl) has many disadvantages. Objective: The present study was aimed to explore newer irrigation solutions, which would probably be as effective as NaOCl. Materials and Methods: Extracted human single rooted premolar teeth were biomechanically prepared, vertically sectioned, placed in tissue culture wells exposing the root canal surface to E. fecalis is grown on Mueller Hinton agar plates to form a biofilm for 6 weeks. At the end of 6 ^th week, all seven groups were treated with 3 ml of test solutions and control for 10 minutes and evaluated for E. fecalis growth and number of colony forming units. Results: Propolis, NaOCl and triphala showed no statistically significant difference, whereas all the other inter-group differences were statistically significant (Tukey's honest significant difference (HSD)) (P < 0.001). Conclusion: Propolis and triphala were found to be as efficacious as NaOCl. The use of herbal alternatives as root canal irrigation solutions might prove to be advantageous considering several unfavorable properties of NaOCl.

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Objective: This study aimed to investigate the bactericidal effect of silver nanoparticles (AgNPs) in reducing bacterial infection in root canal when used as intracanal medicament alone or in addition to the conventionally used calcium hydroxide (Ca(OH)₂). Materials and Methods: The root canals of 110 single-rooted teeth were cleaned, shaped, and sterilized. All groups, except for negative control, were inoculated with Enterococcus faecalis for 48 h. Then, teeth were divided into five groups according to the intracanal medicaments to be used. Group I (n = 30): Ca(OH)₂. Group II (n = 30): AgNP. Group III (n = 30): AgNP + Ca(OH)₂. Group IV (n = 10) was used as a positive control where the root canals were inoculated with E. faecalis and left without treatment. Group V (n = 10) was used as a negative control where the root canals were checked for the absence of bacterial growth. Specimens were incubated for 1 and 2 weeks. Pre- and post-medication samples were obtained by paper points, and the colony-forming units were counted. Results: Ca(OH)₂ resulted in a higher percentage of bacterial reduction in both 1 and 2 weeks of application (81.5% and 98%, respectively). AgNP was ineffective against E. faecalis with 32.9% bacterial reduction in 1 week and 56.5% after 2 weeks. Conclusion: It was concluded that the antibacterial effect of AgNP was lower than Ca(OH)₂ or combination of both materials.

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Objective: We evaluated knowledge of technical aspects of non-surgical root canal treatment among general dentists in private dental clinics in Al-Madinah Al-Munawarah, Saudi Arabia. Materials and Methods: A questionnaire was distributed randomly to 70 general dental practitioners who were working in private dental centers. The response rate was 88.6%. Results: The results showed that only 3% of dentists were using rubber dams for isolation during endodontic treatment. The majority (59.7%) were using radiographs to determine the length. Also, 37% were using nickel-titanium (NiTi) rotary instruments to prepare the root canal. The lateral condensation technique with gutta percha points to fill the root canal was used by most respondents (77.5%). Conclusions: This study provides important data on endodontic treatment by general dental practitioners in Al-Madinah Al-Munawarah private dental centers. It shows a general lack of knowledge regarding the importance of using rubber dams as well as the new endodontic materials and methods. Continuing education programs to update their knowledge in the field of endodontics are essential.

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Aim: To determine the prevalence of the number of root canals in permanent maxillary first and second premolars of a Saudi Arabian sub-population. Results will be compared to previous Asian studies. Materials and Methods: A total of 894 periapical radiographs of endodontically treated maxillary first and second premolars of 628 Saudi patients (268 males and 360 females) were viewed. The teeth were segregated into maxillary first premolars (463) and maxillary second premolars (431). The diagnostic, working length, master cone and final films with different angles were mounted, projected and, with the utilization of written clinical records, evaluated. Teeth with multiple canal systems were categorized according to whether the canals exited the root by common or separate apical foramen. Data was analyzed statistically using Chi-square test and professional t-test, by comparing pairs of groups with the significant level established at 5% (P < 0.05). Results: More than 90% of first maxillary premolar and more than 50% of the second maxillary premolar was found to have two canals. There was no significant difference between male (92%) and female (95%) in the distribution of the two root canals of the first maxillary premolar (t-test = 1.21, P value = 0.228), however, there was significant difference between the distributions of male (69.4%) and female (52.2%) of the two root canals within the second maxillary premolar (t-test = 3.75, P value = 0.000). Few teeth showed three canals. Conclusion: The number of root canals of the maxillary first premolar in Saudi population shows a higher incidence of two canals (93.6%) than previously reported. In addition, the figure is higher than most of the Asian countries.

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Objective: The aim of the study was to assess the radiographic quality of root fillings done by the undergraduate students. Materials and Methods: A sample of 258 clinical cases of patients who received root canal treatment from undergraduate students in the years 2010 to 2012 were selected, out of which 194 root fillings were assessed radiographically based on the following criteria; length and density of root filling. Root fillings were categorized as acceptable and unacceptable. Percentages and χ² test were used for statistical analysis. Results: From the 194 root fillings, 119 (61.35%) were having acceptable and 75 (38.65%) were having unacceptable root fillings. From the total 75 unacceptable root fillings, 49 (65.33%) had density problems, 11 (14.66%) were overfilled, and 15 (20%) were under filled. Chi-square test was done for statistical analysis; revealed no significant difference in the radiographic quality between anterior and posterior root fillings. Conclusion: The radiographic quality of root fillings done by undergraduate students was acceptable in 61.35% cases. Most common cause of unacceptable fillings was due to density problems compared to overfilling and under filling. Results from the study indicate that remedial measures have to be undertaken to improve training of undergraduate students in root canal treatment procedure.

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The aims of this paper were to review the studies that investigated the root and root canal morphology of permanent dentition in the Saudi Arabian population and to compare their results with the findings of international morphological studies conducted on other populations. An electronic search using the PubMed and Scopus databases was conducted using combination of the following keywords: "root canal morphology", "root morphology", "dental anomalies", and "Saudi Arabian population". In addition, all issues of the Saudi Dental Journal (since 1989) and Saudi Endodontic Journal (since 2011) were manually searched for relevant articles. Then, the reference lists of the articles were screened to identify further eligible publications. A total of 23 studies met the inclusion criteria and were subjected to data extraction and analysis. Variations from the normal root and canal morphology may occur in all populations including the Saudi Arabian population. Therefore, the clinicians must always take these variations in consideration during root canal treatment to ensure a successful treatment outcome.

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The use of triple antibiotic paste (TAP) (mixture of ciprofloxacin, metronidazole and minocycline) as an intra-canal medicament have shown very encouraging results particularly in non-vital immature teeth associated with periradicular lesions. Hence, before opting for a surgical approach, a non-surgical approach can be thought of with extended use of TAP as intra-canal medicament, especially in patients who are phobic to invasive procedures. On the flip side, the use of TAP has few side-effects, of which one is the discoloration it can cause due to the presence of minocycline in the mix. The purpose of this article is to presents a case of coronal discoloration due to the use of TAP as an endodontic intra-canal medicament.

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Aim: The aim of this study was to compare the calcium hydroxide (Ca(OH) ₂ ) removal efficacy of the EndoActivator system with that of conventional irrigation with a syringe and hand file manipulation. Materials and Methods: A total of 44 extracted human single-rooted mandibular premolars were used. The root canal systems of all teeth were cleaned and shaped, then filled with Ca(OH) ₂ paste. The teeth were divided into two groups: Ca(OH) ₂ was removed using ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite (NaOCl) with hand filing and irrigation (Group 1) or the EndoActivator system (Group 2). Each tooth was split into two halves and examined under a scanning electron microscope. Results: Ca(OH) ₂ particles were completely removed at the coronal level in both experimental groups. More Ca(OH) ₂ particles were present in the apical third than in the middle-third in both groups. No significant interaction was observed between the two experimental groups or among the three examined levels (P > 0.05). Conclusion: Agitation with NaOCl and EDTA improved Ca(OH) ₂ removal only in the coronal third of the root canal. Use of the EndoActivator system did not improve the efficacy of Ca(OH) ₂ removal in the middle and apical thirds.

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Aim: The purpose of this in vitro study is to provide clinical data on the presence of the second canal in mandibular incisor teeth of Saudi Arabian Samples. Materials and Methods: Eighty extracted human mandibular incisors were collected from Saudi patients. The teeth were accessed by small round bur then placed in 5.25% sodium hypochlorite for 24 hours to dissolve the organic debris. Indian ink was injected inside the root canal systems under negative pressure. The teeth were decalcified in 5% nitric acid for three days then dehydrated in different concentrations of ethyl alcohol. Following the decalcification process, the teeth were cleared in methyl salicylate and evaluated according to Vertucci's classification. Result: Fifty six of both mandibular central and lateral incisor teeth (70%) had type I canal configuration (one main canal and one main apical foramen), while the remaining 30% of the sample (24 teeth) had a type III canal configuration (two separate canals and merged into one canal before exiting the tooth through single apical foramen). Conclusion : The incidence of two canals in mandibular incisor teeth is about one third of the examined Saudi Arabian samples with no difference between the centrals and laterals. The clinician should deal with these teeth as if they have two canals unless it is proved otherwise.

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Aim: To evaluate and compare the antibacterial efficacy of Melaleuca alternifolia (tea tree oil), Curcumalonga (turmeric), 2% chlorhexidine (CHX), and 5% sodium hypochlorite (NaOCl) against Enterococcus faecalis. Materials and Methods: Agar plates were prepared using tryptone soya agar. Cultures of E. faecalis were grown in tryptone soya broth. Agar well diffusion method was performed and the plates were incubated at 37΀C for 24 h. The zones of inhibition were recorded. The readings were subjected to statistical analysis using analysis of variance (ANOVA) and Tukey's post hoc test. P-value was considered significant at P < 0.05. Results: Maximum antibacterial efficacy was exhibited by 2% CHX, followed by 5% NaOCl and C. longa with no statistically significant difference between them. It was followed by M. alternifolia (Tea tree oil). Ethanol and saline showed the least antibacterial action. Conclusion: According to the results of this study, C. longa and M. alternifolia can be used as an alternative root canal irrigant, although long-term in vivo studies are warranted.

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Aim and Objectives: The aim of this study was to test the dentinal tubule penetration of mineral trioxide aggregate (MTA) Fillapex (Angelus, Londria, PR, Brazil), GuttaFlow^® 2 sealer (Coltene/Whaledent) with standard sealer AH Plus (Dentsply Detrey, Konstanz, Germany) in instrumented root canals obturated by using cold lateral compaction techniques in either the presence or absence of the smear layer. Materials and Methods: Sixty extracted human mandibular premolars with a single root canal were used for this study. All teeth were prepared using F2 Pro Taper nickel–titanium rotary system. Teeth were randomly divided into three groups of 20 teeth each. GuttaFlow 2, MTA Fillapex and AH Plus were used as sealers in Group I, Group II, and Group III, respectively. Groups were divided into two subgroups in which either the smear layer was removed or retained. Removal of smear layer was achieved by continuous irrigation with 5.25% sodium hypochlorite and 2 ml of 17% ethylenediaminetetraacetic acid. The canals were dried and obturated using respective sealers by cold lateral compaction techniques. After storage at 37°C and 100% humidity for 14 days, the roots were then split into two halves using chisel and mallet. On each section, sealer penetration in the dentinal tubules at cervical, middle, and apical levels was examined by using scanning electron microscope. Results: Sealer penetration into the dentinal tubules was noticed in all groups. AH plus showed deeper penetration, followed by MTA Fillapex and GuttaFlow® 2. The penetration depth of the sealers at the cervical and middle third of root was significantly more than those at apical third. Conclusions: Within the parameters of the present study it was concluded, with the removal of smear layer AH plus sealer showed deeper penetration into the dentinal tubules at cervical and middle third of root compared with apical third.

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Radix entomolaris (RE) is considered to be an Asiatic trait. However, its prevalence in Indian population is found to be lower than in other Asian races. Nevertheless, its awareness and identification is vital to achieve endodontic success. This article presents a review on clinical approach and a case series on the detection and endodontic management of RE in mandibular first molars. Radix entomolaris was detected by identifying the presence of a double or extra root outline in the preoperative radiograph, modifying the access opening and closely inspecting the pulp chamber and was endodontically treated following cleaning, shaping, and obturation of the canals. Achieving the endodontic success in the presence of an RE requires knowledge about its prevalence, diagnosis, morphology, canal configuration, and clinical approach.

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Traumatized anterior teeth with sub-gingival crown fractures are a challenge to treat. The management of sub-gingival fractures includes exposing the cervical margin followed by appropriate coronal restoration. The treatment modalities, which involve exposing the cervical margin, are surgical crown lengthening and orthodontic extrusion. This paper reports a case of fractured maxillary anterior tooth at the sub-gingival level that was managed by forced orthodontic extrusion after endodontic treatment followed by esthetic rehabilitation, a much forgotten technique not utilized routinely yet conservative and cost-effective.

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This case report describes the successful management of complicated crown fracture of left maxillary central incisor (#21) of 23-year-old male using dentin (biological) post made from human tooth. Endodontic treatment was initiated and sectional obturation was done using ProTaper gutta-percha and AH Plus sealer. The coronal space was modified to receive a human dentin post. A two-step procedure comprising direct and indirect technique of post fabrication was done to achieve the accuracy of biological post. A maxillary cuspid from an institutional tooth bank was taken, sectioned mesiodistally using a diamond disc simulating the length and thickness of mock post. Dentin post was first verified on the plaster model and then cemented in tooth #21. Core build up was done with composite and porcelain fused to metal (PFM) crown was luted. On the follow-up visits, patient was asymptomatic and radiographic evaluation revealed normal periradicular architecture. Biological posts may be good alternatives to conventional post systems as they preserve internal dentin walls, provide excellent adhesion, and resilience similar to natural tooth structure.

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Iatrogenic root perforations, which may have serious implications, occur in approximately 2-12% of endodontically treated teeth. Successful management of root perforations is dependent on early diagnosis of the defect, location of the perforation, choice of treatment, materials used, host response, and the experience of the practitioner. This report presents the successful management of an iatrogenic perforation in a tooth with radiographic evidence of pulp canal obliteration.

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A radicular cyst arises from epithelial remnants stimulated to proliferate by an inflammatory process originating from pulpal necrosis of a non-vital tooth. Radiographically, the classical description of the lesion is a round or oval, well-circumscribed radiolucent image involving the apex of the tooth. A radicular cyst is usually sterile unless it is secondarily infected. This paper presents a case report of conservative non-surgical management of a radicular cyst associated with permanent maxillary right central incisor, right lateral incisor and right canine in a 24-year-old female patient. Root canal treatment was done together with cystic aspiration of the lesion. The lesion was periodically followed up and significant bone formation was seen at the periapical region of affected teeth and at the palate at about 9 months. Thus, nonsurgical healing of a large radicular cyst with palatal swelling provided favorable clinical and radiographic response.

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Aim: To evaluate the microleakage of a simplified etch-and-rinse adhesive bonded to pulp chamber dentin with water-wet bonding (WWB) or ethanol-wet bonding (EWB) with and without proanthocyanidins (PA) application. Materials and Methods: Total 88 non-carious extracted human molar teeth were sectioned horizontally to expose the pulp chambers 1.5 mm coronal to the cemento-enamel junction. After the pulp tissue extirpation, canal orifices were enlarged and the root ends were sealed. The samples were randomly divided equally into following four groups according to the four bonding techniques performed using Adper Single Bond 2 [SB] adhesive (1) WWB; (2) EWB; (3) WWB and PA application [WWB + PA]; (4) EWB and PA application [EWB + PA]. Composite resin restorations were performed in all the pulp chambers. Total 20 samples from each group were subjected to microleakage evaluation, and two samples per group were assessed under scanning electron microscope for interfacial micromorphology. Results: The least microleakage score was observed in group 2 (EWB) with similar results seen in group 4 (EWB + PA) (P = 0.918). Group 2 (EWB) showed significantly less microleakage than group 1 (WWB; P = 0.002) and group 3 (WWB + PA; P = 0.009). Group 4 (EWB + PA) also depicted significantly reduced microleakage as compared with group 1 (WWB; P = 0.001) and group 3 (WWB + PA; P = 0.003). Conclusion: The use of EWB technique in a clinically relevant simplified dehydration protocol significantly reduced microleakage in simplified etch-and-rinse adhesive, Adper Single Bond 2, bonded to pulp chamber dentin. Application of PA had no significant effect on the microleakage of the adhesive bonded with either WWB or EWB.

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Aim: The aim of this study is to evaluate radiographically the quality of root canal filling in mesiodistal and buccolingual view when comparing matched cone condensation and warm lateral Gutta-percha condensation using system B heating instrument in a low-heat warm lateral condensation technique in0 vitro. Materials and Methods: A total of 40 mandibular premolars with straight single canals were divided into two groups with 20 each. The root canals were shaped by hand file and Revo-S rotary files to size (25, 0.06) at the end point, then they filled by Gutta-percha cone and meta-seal sealer. In group A, a single matched cone technique was used to fill the root canals. In group B, a hot lateral condensation using system B instrument at 101°C was performed. Result: The result of this study showed no significant difference in density of Gutta-percha fill in apical and coronal two-third when comparing matched cone root canal filling and hot lateral technique (P > 0.05). The only significant difference (P < 0.05) was in matched cone between buccolingual and mesiodistal view in the coronal two-third. Conclusion: Within the limitation of this study, single matched cone technique has a good density in the apical one-third as that of the hot lateral technique so it may be used for filling narrow canals. In the coronal two-third of the root canal, single matched cone technique showed inferior density of root canal filling which can be improved by using accessory cones Gutta-percha in wide canal.

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Aim : The purpose of this study was to comparatively evaluate the antibacterial property of various concentrations of green tea extracts and 2% chlorhexidine (CHX) against Enterococcus faecalis 0(E. faecalis) in vitro. Materials and Methods: The activity of green tea extract and CHX on E. faecalis was measured on agar plates using the agar diffusion method. In addition, the tube dilution method was used to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration of green tea extract against E. faecalis. Results: The MIC of green tea extract was found to be 3.5%. The zone of inhibition was found to be concentration dependent. The 2.5% concentration of green tea extract showed 20 mm zone of inhibition, while the 3% concentration demonstrated a 30 mm zone of inhibition. Two percent CHX showed 30 mm zone of inhibition. Conclusion: Three percent concentration of green tea extract showed an antibacterial activity equivalent to 2% CHX against E. faecalis.

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Aim: The aim of this study was to analyze the cytotoxicity of various volumes of 5.25% of sodium hypochlorite, 2% of chlorhexidine gluconate and mixture of a tetracycline isomer, an acid and a detergent (MTAD) by checking for hemolysis of human red blood corpuscles. Materials and Methods: A total volume of 100 μl of diluted red blood corpuscles obtained through centrifugation was added to three irrigating solutions (5.25% of sodium hypochlorite, 2% of chlorhexidine and MTAD) of six test tubes each. Individual irrigants per group were added in increasing volume starting from the second test tube keeping the first one as the control. After incubation for 3 min hemoglobin content was measured using an automated hemoanalyzer data was analyzed using one sample t-test. Results: Sodium hypochlorite is the most cytotoxic solution followed by MTAD and chlorhexidine. Conclusions: This study suggests that the three irrigating solutions do cause detrimental effects on the diluted red blood corpuscles. A great deal of care should therefore be exercised when using 5.25% sodium hypochlorite during endodontic irrigation.

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Aim: The aim of our study is to elaborate a new cement based on Portland cement (PC), Modified Portland Cement (MPC) with modified chemical and physical properties that allow easier clinical manipulation and faster setting time than MTA^® and then to evaluate its cytotoxicity in vitro and its biocompatibility in vivo in comparison with MTA^® . Materials and Methods: Elaboration of MPC: Portland cement powder slenderly grinded to homogenize the particles, mixed with a radiopaque element and a setting time accelerator. A comparative in vitro study (MTS test) of the toxic effect of MTA^® and MPC with culture isolated from the calvaria of 18-day-old fetal Swiss OF1 mice are done. A comparative in vivo study of the biocompatibility of MTA^® and MPC: Under general anaesthesia, three holes (2.5 mm) were made in both the left and right femurs of six White New Zealand rabbits. In the first hole MPC is placed, in the second MTA^® and the third one is left empty (negative control group). Three weeks after implantation, two rabbits are sacrificed, then two other rabbits over six weeks and the last two after twelve weeks. The neck of the femur is trimmed and prepared for undecalcified histological studies. Mann-Whitney test was used to analyze the results. Results: The cell viability test according to the morphological observations suggested the biocompatibility of the two biomaterials tested. The in vivo test showed similar biocompatibility between MTA^® and MPC. Bone healing and minimal inflammatory response adjacent to MTA^® and MPC implants were observed at all experimental periods (3, 6 and 12 weeks), suggesting that both materials are well tolerated. Conclusion: This pilot comparative study of MTA^® and MPC showed no or very limited toxic effects of both cements in vitro and similar biocompatibility in vivo. However, additional in vivo and clinical studies should be done on MPC before it can be introduced in our clinical practice.

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The aim of this review was to evaluate studies assessing the accuracy of Root ZX when used for working length determination in permanent teeth and to identify factors affecting the device's precision. An electronic search for articles published in English language since 1994 was conducted on the Medline via Ovid interface. All issues of the International Endodontic Journal, Journal of Endodontics and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology since 1994 were manually searched. The reference lists of review articles were cross-referenced to identify any potential publications. A total of 76 publications fulfilled the inclusion criteria. The studies varied in their methodologies, and most of them did not adhere to the manufacturer's recommendations while operating the device. The Root ZX failed to consistently detect the apical constriction or the apical foramen. Nonetheless, it mostly allowed file tip placement in the area bounded by these two landmarks, especially when the 0.5 mark of its digital meter was adopted. Tooth-related factors potentially influencing the precision of Root ZX included pre-operative pulp status, tooth type, position of the apical foramen, canal obliteration, and the size of apical diameter. Operative factors including coronal pre-flaring, presence or absence of irrigants, file size, file alloy, and mode of file operation could also influence the performance of Root ZX. In conclusion, adopting the 0.5 mark of the digital meter of the Root ZX reduces chances of violating the apical foramen. Further, factors influencing the precision of Root ZX must be considered while operating it.

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The use of radiographs for working length determination is usual practice in endodontics. Exposing radiographs following the principles of the paralleling technique allows more accurate length determination compared to the bisecting-angle method. However, it has been reported that up to 28.5% of cases can have the file tip extending beyond the confines of the root canals despite an acceptable radiographic appearance. The accuracy of radiographic working length determination could be affected by the location of the apical foramen, tooth type, canal curvature and superimposition of surrounding structures. Variations among observers by virtue of training and experience may also influence the accuracy of the procedure. The interpretation of radiographs could be affected by film speed and viewing conditions, with the superiority of digital imaging over conventional radiography for working length determination remaining debatable. The combination of several methods is recommended for acquiring the most accurate working length.

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Studies on the anatomy of the root apex are an area of interest to the endodontist; they have reported that the position of the apical constriction, apical foramen and the cemento-dentinal junction varies across the tooth types. These anatomical apical landmarks are considered extension limits for root canal instrumentation and filling. Achieving an optimum working length is thought essential for successful root canal treatment, so adopting any of these landmarks is associated with certain risks and benefits. The variability in the position of the apical constriction and apical foramen, for example, complicates their clinical detection, while the cemento-dentinal junction is a histological landmark that cannot be detected clinically. The radiographic apex does not always coincide with the anatomic apex of the tooth. The pre-operative status of the pulp must be considered while obtaining the working length. Most prognostic studies agree that extending the root filling to within 2-3 mm of the radiographic apex is associated with favorable treatment outcomes.

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