Background: The primary goal of root canal treatment is the prevention and healing of apical periodontitis through the meticulous elimination of pathogenic bacteria and infected tissues. Within this framework, apical patency remains a fundamental yet debated clinical concept. Objectives: This review aims to evaluate the clinical significance of maintaining apical patency, its influence on postoperative discomfort, and the technical strategies required for predictable negotiation. Methods: We performed a comprehensive review of existing literature, including clinical studies and recent meta-analyses, focusing on the correlation between patency maneuvers and postoperative pain, the role of preoperative CBCT imaging, and the efficacy of specialized negotiation instruments and motor kinematics. While patency facilitates thorough debridement, evidence regarding its impact on postoperative pain is conflicting, with recent meta-analyses suggesting it may actually alleviate discomfort intensity. Preoperative CBCT was identified as essential for identifying complex anatomy, such as the MB2 canal. Furthermore, the use of specialized files and reciprocating motor modes enhances the predictability of glide path establishment. Conclusions: Although failure to achieve patency does not always dictate a negative outcome, it is associated with improved long-term healing. Clinicians should prioritize “Anatomical Patency”—respecting original morphology—over forceful “Operative Patency” to ensure procedural integrity and clinical success.
Ishizaki et al. (Wed,) studied this question.