Challenges in working length determination

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working length determination in endodontics poses great challenges, even tooth formation determines the fate of endodontic treatment in the future

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Challenges in working length determination

  1. 1. Challenges in Working length determination By Dr.Anoop.V.Nair PG Dept of Cons & Endo KVG Dental College
  2. 2. Contents • Introduction to methods of working length determination • Anatomy of root apex • Significance of working length • Methods of working length determination in brief- Radiographic methods - Non- radiographic methods - Apex locators • Anatomic basis for challenges in working length determination • Apical root anatomy and its impact on working length • Overcoming challenges in radiographic techniques • Overcoming challenges in apex locators • Overcoming challenges in other methods • Controversies and Challenges With the Pulpal and Periapical Status and Their Impact on Working Length Determinations and Choices • Conclusion • References
  3. 3. “The healing processes after removal of a pulp, occur in the tissue immediately adjacent to the point where the pulp was severed. It is, therefore, of great importance to retain the vitality of these tissues in order to make healing possible.” R. Kronfeld , 1933 “If the tooth is uncomfortable, however, or presents an area of rarefaction, apical access must be obtained in order to negotiate the canal throughout its entire length to reach the periapical tissues.” L.I. Grossman, 1946 “Factors that may influence a difference [in the method used for working length determination] include the quality of radiographs, superimposed anatomic structures, or anomalous positions of root canal foramen.” D.H. Pratt en, N.J. McDonald, 1996
  4. 4. An introduction
  5. 5. Working length- definition The seventh edition of the Glossary of Endodontic Terms defines the working length of a tooth as the distance from a coronal reference point to the point at which canal preparation and obturation should terminate.
  6. 6. Reference point- definition • It is the site on the occlusal or incisal surface from which measurements are made. • This point is used throughout canal preparation & obturation. • Selection • Should be easily visualized during preparation. • Usually the incisal edges in anteriors & buccal cusp tip on posteriors. • Stability • A reference point that will not change during or between appointments is selected. • Examples of unstable reference points are undermined cusps or cements.
  7. 7. Three main issues are presently considered most challenging and controversial in root canal shaping: • Identification, accessing, and enlargement of the main canals without procedural errors • Establishing and maintaining adequate working lengths throughout the shaping procedure • Selection of preparation sizes and overall geometries that allow adequate disinfection and subsequent obturation.
  8. 8. • An accurate working length is one of the most important criteria for achieving successful endodontic results and minimising post-operative discomfort. • An erroneous working length, either long or short, can compromise the outcome of the case from the beginning. • An erroneously short working length leaves uncleaned and unfilled canal space in the apical region. • An erroneously long working length will lead to over-instrumentation and overextended obturation, causing significant post-operative discomfort.
  9. 9. The instrumentation and obturation of root canals should end at the apical constriction (physiologic foramen) for the following reasons:  no apical injury  no injury to the periodontal ligament  maintenance of accessory lateral canals  no extrusion of root canal fi lling material  no apical transport of infected pulpal tissues  adequate compaction of the root canal filling against the canal walls  no infected tissue remnants within the canal • In the case of a vital tooth, the clinician’s primary concern is to keep the apical wound as small as possible, while with a necrotic pulp the main concern is removal of all bacteria. • Both of these objectives can be met by terminating the apical extent of root canal instrumentation in the region of the apical constriction.
  10. 10. 1. Tooth apex (radiographic apex) 2. Apical foramen (major foramen) 3. Apical constriction (minor foramen) 1 2 3 Anatomy of the Root Apex (Kutler’s studies)
  11. 11. 1 2 3 • Distance between 1 and 2:  The apical foramen deviates from the apex in 50-98% of the teeth.  This deviation averages 0.3 to 0.6 mm but could be as much as 3 mm. 1. Tooth apex (radiographic apex) 2. Apical foramen (major foramen) 3. Apical constriction (minor foramen) Anatomy of the Root Apex
  12. 12. 1 2 3 • Distance between 2 and 3:  0.5 mm in 18-25 y old, and 0.7 in 55+ y old. • Distance between 1 and 3:  0.89 mm with a range of 0.1 to 2.7 mm. 1. Tooth apex (radiographic apex) 2. Apical foramen (major foramen) 3. Apical constriction (minor foramen) Anatomy of the Root Apex
  13. 13. Significance of working length • Determines how far into the canal the instruments are placed and worked and thus how deeply the tissues, debris, metabolites are removed. • Limits the depth to which the canal filling may be placed • Affects the degree of pain & discomfort that the patient will feel following the appointment • If calculated within correct limits, it will play an important role in determining the success of the treatment & conversely, if calculated incorrectly, may doom the treatment to failure.
  14. 14. Methods of determining working length 1. Radiographic method- • Grossman formula • Ingles method • Weine’s method • Kutler’s method • Radiographic grid • Endometric probe • Xeroradiography • Radio Visiography • Subtraction radiography 2. Non Radiographical methods- Digital tactile sense Apical periodontal sensitivity Electronic apex locator Paper point method
  15. 15. Radiographic method • Radiographic apex used as termination point. • Quality of image is important for accurate interpretations. • When two superimposed canals present, either- A. Take 2 individual radiographs with instrument placed in each canal B. Take radiograph at different angulations, usually 20-40o at horizontal angulations. C. Insert two different instrument- K file in one canal, H file in other canal and take radiographs at different angulations. D. Apply SLOB rule, that is expose tooth from mesial or distal horizontal angle, canal which moves to same direction, is lingual where as canal which moves to opposite is buccal.
  16. 16. Ingles method • Pre-op radiograph is used to calculate the working length. • Measurement can be confirmed by placing an endodontic instrument into the canal and taking a second radiograph • Instrument inserted should be large enough not to be loose in the canal because it can move while taking the radiograph and thus may result in errors in determining the working length • Fine instruments are often difficult to be seen in a radiograph • The new working length is calculated by adding or subtracting the distance between the instrument tip and desired apical termination of the root. • The correct working length is calculated by subtracting 1 mm as safety factor from this new length.
  17. 17. Weine’s subtraction rule • If radiograph shows absence of any resorption i.e, bone or root apex, shorten the length by 1mm • If periapical bone resorption is present, shorten it by 1.5mm • If both bone and root resorption is seen, shorten length by 2mm. This is done because if there is root resorption, loss of apical constriction may occur in such cases
  18. 18. Advantages • One can see the anatomy of tooth • One can find out curvatures of the canal • We can see the relationship between adjacent teeth and anatomic structures Disadvantages • Varies with different observers • Superimposition of anatomical structures • Two dimensional view of three dimensional object • Cannot interpret if apical foramen has buccal or lingual exit • Risk of radiation exposure • Time consuming • Limited accuracy
  19. 19. Grossman method/ mathematic method of working length determination • An instrument is inserted into the canal, stopper is fixed to the reference point and radiograph taken. • The formula to calculate actual length of the tooth is as follows: Actual length of the tooth = apparent length of tooth in radiograph Actual length of the instrument apparent length of the instrument in radiograph Hence, Actual length of the tooth = actual length of instrument x apparent length of tooth in radiograph apparent length of instrument in radiograph
  20. 20. Kuttler’s method • According to Kuttler, canal preparation should terminate at apical constriction, i.e, minor diameter. • In young patients, average distance between minor and major diameter is 0.524 mm where as in older patients its 0.66 mm. Technique: • Locate minor and major diameter on preoperative radiograph • Estimate length of roots from preop radiograph • Estimate canal width on radiograph. If canal is narrow, use 10 or 15 size instrument. If it is of average width, use 20 or 25 size instrument. If canal is wide, use 30 or 35 size instrument. • Insert selected file in canal upto the estimated canal length and take a radiograph. • If file reaches major diameter, subtract 0.5mm from it for younger patients and 0.67 for older patients.
  21. 21. Advantages • Minimal errors • Has shown many successful cases Disadvantages • Requires radiograph of highest quality • Time consuming • Complicated
  22. 22. Radiographic grid • Everett & Fixott in 1963. • Millimeter grid is superimposed on the radiograph • This overcomes the need for calculation. • Not a good method if radiograph is bent during exposure Endometric Probe • One uses graduations on diagnostic file which are visible on radiograph. • Its main disadvantage is that the smallest file size to be used is number 25
  23. 23. Direct digital radiography • Digital image is formed which is represented by spatially distributed set of discrete sensors and pixels. Two types of digital radiography: a. Radiovisiography b. Phosphor imaging system
  24. 24. Xeroradiography • Filmless, image recorded on aluminium plate coated with selenium particles. • Plate removed from cassette and subjected to relaxation which removes old images, then these are electrostatically charged and inserted into the cassette. • Radiations are projected on film which cause selective discharge of the particles. • This forms the latent image and is converted to a positive image by a process called ‘development’ in the processor unit.
  25. 25. Advantages • Technique offers ‘edge enhancement’ and good detail • Ability to have both positive and negative prints together • Improves visualization of files and canals together • Two times more sensitive than conventional D speed films Disadvantages • Saliva acts as a medium for flow of current, the electric charge over the film may cause discomfort to the patient • Exposure time varies according to thickness of the plate • The process of development cannot be delayed beyond 15 mins
  26. 26. Electronic Apex Locators (locates apical foramen/constriction) • The idea of using electrical conductance to measure root length was suggested first by by Cluster in 1918. Cluster LE, J Natl Dent Assoc, 1918 • In 1942 Suzuki noticed a constant value of electrical resistance between an instrument in the root canal and an electrode on the oral mucous membrane and speculated that this would measure canal length. Suzuki K, J Jpn Stomatol, 1942 • In 1962 Sunada took the principle of Suzuki and constructed a simple device that used direct current to measure canal length. This was based on the concept that the resistance between the periodontium and the mucous membrane was constant and equal 6 k . Sunada I, J Dent Res, 1962
  27. 27. Digital tactile sense • In this clinician may see an increase in resistance as file reaches the apical 2-3mm • Time saving, no radiation exposure • Do not provide accurate diagnosis always, resistance felt earlier in narrow canals, in case of teeth with immature apex instrument can go periapically
  28. 28. Periodontal sensitivity test • Based on patient’s response to pain • This method does not provide accurate readings, for example in case of narrow canals, instrument may feel increased response in apical 2-3mm, immature apex, file goes beyond apex. • In case of canals with necrotic pulp, instrument can pass beyond apical constriction, and in case of vital or inflamed pulp, pain may occur several mm before periapex is crossed by instrument.
  29. 29. Paper point measurement method • Most reliable in cases of open apex where apical constriction is lost because of perforation or resorption. • Moisture or blood present on apical part of paper point indicates paper point has passed beyond estimated working length. • Used as a supplementary method.
  30. 30. Electronic Apex Locators First generation • Resistance type (measure opposition to flow of current) based on the principle of Suzuki and Sunada. • Root canal meter, Endodontic meter, Dentometer and Endo Radar. • Pain was felt during earlier models due to high currents. • Easily operated, audible indication, detects perforation, can be used with K file • Unreliable, electrolytes, exudate, hemorrhage, vital pulp tissue, and excessive moisture caused inaccurate results. • Patient sensitivity, requires calibration, requires good contact with lip clip
  31. 31. Electronic Apex Locators Second generation • Single frequency impedance • Highest impedance (opposition to flow of alternating current) at the apical constriction. • Need to be calibrated before each use. • Sono-Explorer, Endocator (sheath over probe), Apex finder, Endoanalyzer, Digipex, Digipex II, Formation IV. • Root canal has to be free of electroconductive materials to obtain accurate readings. • Does not require lip clip, analog method
  32. 32. Electronic Apex Locators Third generation • Frequency dependent apex locator • Based on fact that different sites in canal give difference in impedence between high and low (8 Khz- 400 Hz) • Calculate difference or ratio of impedance. • Difference in impedence is least in the coronal part of the canal. • As probe goes deeper into canal, difference increases, greatest at CDJ. • ‘Comparitive impedence’- because they measure relative magnitudes of impedence which are converted into length information. • ‘Endex’- Yamaoka et al., Neosomo ultimo, EZ apex locator, Mark V plus, Root ZX, Tri auto ZX, Endy 7000, Sofy ZX • Easy to use, uses K file, audible indication, can operate in presence of fluids, analog read out • Requires lip clip, chances of short circuit
  33. 33. Electronic Apex Locators Fourth generation • Measures resistance and capacitance separately • There can be different combination of values of capacitance and resistance that provides the same foraminal reading • This is broken down into primary components and measures separately for better accuracy and thus less chances of occurrence of errors • Eg- SybronEndo elements apex locator
  34. 34. Electronic Apex Locators Fifth generation Propex® II Apex Locator from Maillefer features a new generation, full colour visual display for improved tracking of the files. It also has the latest multi frequency technology incorporated into this 5th generation apex locator and an extended apical zoom function, which activates when the file reaches the apical area, assisting the dentist to locate the apex in most types of root canal conditions. The Propex II apex locator has a small footprint and operates on a rechargeable battery, so it can be moved between dental surgeries with ease.
  35. 35. Electronic Apex Locators Third generation • Endex has an average accuracy of 81% to within + 0.5 mm of the apical foramen. Investigator Accuracy (%) Test condition Compared with Fouad et al. (1993) 73 (±0.5 mm) In vitro - NaOCI Tooth length Mayeda et al. (1993) 66 (±0.75 mm) In vivo Tooth length Frank & Torabinejad (1993) 90 (±0.5 mm) In vivo RM Felippe 8< Scares (1994) 96.5 (±0.5 mm) In vitro Tooth length Arora & Gulabivala (1995) 72 (±0.5 mm) In vivo Tooth length Pratten & McDonald (1996) 82 (±0.5 mm) In vitro RM and tooth length Lauper etal. (1996) 93 (±0.5 mm) In vivo Tooth length Ounsi & Haddad (1998) 85 (±0.5 mm) In vitro Tooth length Weiger et al. (1999) 59 (±0.5 mm) In vitro - NaOCI Tooth length De Moor et al. (1999) 100 (±0.5 mm) In vitro Tooth length Martinez-Lozano et al. (2001) 68 (±0.5 mm) In vitro Tooth length Accuracy studies for the Endex/ Apit apex locator (Gordon and Chandler, 2004)
  36. 36. Investigator Variable tested Accuracy (%) Compared with Sample (n) Clinical accuracy permanent teeth in vitro Czerw et al. (1995) Accuracy in vitro 100 (±0.5 mm) Tooth length 30 White et al. (1996) Accuracy in vitro 84 (±0.5 mm) Tooth length 51 Ounsi & Naaman (1999) Accuracy in vitro 85 (±0.5 mm) Tooth length 39 Accuracy in the presence of irrigants Shabahang et al. (1996) Accuracy in vivo 96 (±0.5 mm) Extracted tooth length 26 McGinty et al. (1996) Irrigants and accuracy in vitro No difference Tooth length 16 between irrigants Weiger et al, (1999) Irrigants and accuracy in vitro - NaOCI 85 (±0.5 mm) Tooth length 41 Jenkins era/. (2001) Various irrigants and accuracy in vitro No difference Tooth length 30 Meares & Steiman (2002) Accuracy with NaOCI in vitro 83 (±0.5 mm) Tooth length 40 No difference Clinical accuracy permanent teeth in vivo Vajrabhaya & Accuracy in vivo 100 (±0.5 mm) Extracted tooth length 20 Tepmongkol (1997) Pagavino et al. (1998) Accuracy in vivo - SEM 83 (±0.5 mm) Extracted tooth length 29 100 (±1.0 mm) Dunlap et al. (1998) Accuracy vital versus necrotic in vivo 82 (±0.5 mm) Extracted tooth length 34 McDonald et a/. (1999) Accuracy in vivo 95 (±0.5 mm) Extracted tooth length 20 Welk et al. (2003) Accuracy in vivo 91 (±0.5 mm) Extracted tooth length 32 Minor diameter Clinical accuracy in primary teeth Katz et al. (1996) Accuracy in primary teeth - in vitro 100 (±0.5 mm) Extracted tooth length 20 Mente et al. (2002) Accuracy in resorbed primary teeth – 98 (±1.0 mm) Tooth length 24 In vitro Kielbassa et al. (2003) Accuracy in primary teeth - in vivo 64 (±1.0 mm) Extracted tooth length 71 The properties of the Root ZX (Gordon and Chandler, 2004) Root ZX has an average accuracy of 89 % to within + 0.5 mm of the apical foramen.
  37. 37. • When radiographic working length in vitro was set to be 0.5 – 2.0 mm short of the apex and using the Root ZX in premolars:  The proportion of overestimation was reduced from 51% for radiographic method to 21% when the Root ZX was used. ElAyouti A et al., J Endodon, 2002 • Using an apex locator reduces exposure to radiation by minimizing the number of radiographs required to get an acceptable working length radiograph and also produces more accurate working length determination. Brunton P.A. et al., J Endodon, 2002 • Third generation Electronic Apex Locators work well in the presence of different irrigants including NaOCl, EDTA, and RC Prep. Jenkins et al., J Endodon, 2001; Kaufman et al., Int Endo J, 2002; Weiger et al., J Endodon, 1999 • Preflaring the canal increases the accuracy of Electronic Apex Locator reading (Ibarrola et al., J Endodon, 1999) and tactile sensation (Stabholtz et al., J Endodon, 1995). It also reduces the potential reduction in canal length due to the elimination of curvatures.
  38. 38. • Apex locators are not affected with the use of stainless steel files or NiTi files. (Thomas et al., J Endodon, 2003; Nekoofar et al., J Cali Dent Assoc, 2002) • Apex locators are not affected by the size of the file used (Nguyen et al., Int Endo J, 1996). • Although a recent study have shown no effect of 4 types of Electronic apex locators in vitro on Cardiac Pace Maker (Garofalo et al. J Endodon, 2002). Use in patients with Cardiac Pace Maker should be consulted with their cardiologists.
  39. 39. Investigator Country Use % Whitten et al. (1996) USA GDPs 10 Saunders et al. (1999) Scotland GDPs 7.7 Yoshikawa et al. (2001) Japan GDPs 90 Chandler & Koshy (2002) New Zealand GDPs 27.5 Specialists 60 Hommez et al. (2003) Belgium GDPs 16 Electronic apex locator use (Gordon and Chandler, 2004) Acceptance of Electronic Apex Locators
  40. 40. Limitations of Electronic Apex Locators • Touching a metallic restoration will affect performance of Electronic Apex Locators. • Leakage of saliva through cervical caries or open margin will also affect Electronic Apex Locators. • Immature “Blunderbuss” apex will give short readings on Electronic Apex Locators.
  41. 41. Anatomic Basis for Challenges With Working Length Determination • Apex of tooth- complex biological unit composed of cementum, dentin, blood vessels, nerves, and connective tissues. • Long-term success of root canal treatment- relationship between instrumentation and obturation procedures and the anatomy of the apex.
  42. 42. Root formation and development- determined by the Hertwig’s epithelial root sheath (HERS), which maps out the external form of the root. The HERS- double layer of epithelial cells derived from a proliferation of the internal and external dental epithelium The rim of this sheath, the epithelial diaphragm, encloses the primary apical foramen. Multirooted teeth form as a result of the division of the primary apical foramen into two or more sections by “tongues” of epithelium growing inwards from the HERS.
  43. 43. • The root sheath determines the number, size, and external morphology of the roots. • Following initiation of root formation, the HERS becomes fragmented and forms a fenestrated network known as the epithelial cell rests of Malassez. • As the root sheath disintegrates, cells of the connective tissue differentiate into cementoblasts, and cementum is deposited on the dentin. Should the HERS disintegrate before dentin is elaborated, a lateral canal will be formed
  44. 44. Palatal view of a mesial buccal root from a maxillary first molar, showing multiple foramina in the apical third of the root. Large lateral canal leaving the mesial canals and exiting on the distal surface of the mesial root, as evidenced by filling during obturation. Note lateral lesion.
  45. 45. Histologic evidence of a large lateral canal in cross section of the mandibular premolar. Note development of a cystic lesion on the lateral surface of the root. SEM (scanning electron microscopy) view of a lateral canal (1800).
  46. 46. • Development of root length is complete approximately 3 to 4 years after tooth eruption, with apical closure occurring some years later. • Extensive variability exists in the external apical root morphology of human permanent teeth with completed root apices Multiple apical terminations pose clinical problems for working length determination, cleaning and shaping, disinfection, and obturation
  47. 47. • In young teeth with incompletely formed apices, a funnel-shaped opening containing connective tissue (the dental papilla) is the typical appearance
  48. 48. • As apex matures, the opening closes, and cementum is deposited on the apex continuing throughout life to compensate or loss of coronal tooth structure due to erosion, abrasion, or attrition. • With increasing age, the center of the foramen deviates more and more from the vertex or apical center. • Resorptive processes will also alter the morphology of the apical complex. • May be the result of normal remodeling, orthodontic tooth movement, or inflammation of the pulp or periradicular tissues.
  49. 49. Radiograph showing apical resorption of the root apices of two teeth. Tooth on the left has an apical invaginating external resorptive defect that alters the position of the cemental-dentinal junction. Resorbed root apex SEM (scanning electron microscopy) of the same root apex shows significant irregularities.
  50. 50. • Internal morphology at the end of the root canal is determined by the odontoblasts responsible for development of the dentin. • The transition from internal to external morphologic features occurs at the cementum-dentin junction (CDJ), delineated histologically by the odontoblasts. • Coronal to this position, the tissue is classified as pulp tissue. • The soft tissue contained within that portion of the canal apical to the CDJ is not dental pulp but a fibrous connective tissue that originates from the periodontal ligament and supplies the vessels and nerves leading to and from the pulp.
  51. 51. Root apex following root canal filling (RCF) short of the actual root length. Histologic evidence of hard-tissue formation (black arrows) that has formed from cells of the periodontal ligament (PDL) adjacent to root filling material. Note cementum formation (white arrows) on internal aspect of apical foramen. RCF PDL
  52. 52. • The walls of that portion of the canal as it enters the periodontal ligament (PDL) are covered with cementum. • The root canal system tapers from the coronal end to its narrowest part, the constriction (minor foramen), which is usually but not necessarily within dentin. • Early investigations indicated that the “pulp canal anatomy becomes extremely variable in the apical third.” • Contemporarily, the internal morphology of the constriction has been classified into five main types: single constriction point, tapering constriction, multiple constriction, parallel constriction, and blocked.
  53. 53. • Apical to the constriction, the root canal system diverges again to the major foramen that is within cementum. • This hourglass shape dictates that canal cleaning, shaping, and obturation should be confined within dentin and not extend beyond the apical constriction or minor foramen. • The apical portion of the root canal system presents the greatest number of ramifications, with 27.4% of teeth demonstrating accessory and lateral canals or an extensive arborization, also known as an apical delta. Apical delta formation in a demineralized and cleared tooth. Note presence of pulp stones in multiple small canals.
  54. 54. • Studies have shown that the major foramina of most human teeth are distant from both the radiographic and anatomic apex. • The major foramen is distant from the minor foramen or constriction by an average distance of 0.5 mm
  55. 55. Apical Root Anatomy and Its Impact on Working Length • Knowledge of the possible three-dimensional variations (e.g., resorption or changes due to age, trauma, orthodontic movement, periradicular pathology, or periodontal pathosis) may prevent significant damage during working length determination and instrumentation to the cementum that has formed around the apical dentin and to the periapical tissues. • The ideal apical terminus of the working length has been identified histologically as the CDJ. This junction is typified by a constriction or narrowing of the canal space (minor constriction) that provides an ideal point to prepare an apical seat in sound dentin. • There can be vast variability in the nature of this constriction that will have an impact on any technique of working length determination. • The constriction should not be confused with the apical foramen (major constriction), since the constriction is rarely if ever at the tip of the root.
  56. 56. The distance from the foramen to the constriction depends on a multitude of factors such as increased cemental deposition or radicular resorption. Mandibular molar with apical root resorption due to a necrotic, infected dental pulp that destroyed the natural cemental-dentinal junction. Both processes are strongly influenced by multiple factors. Especially in periodontal disease states, the CDJ location has no predictable anatomic appearance or location, owing to resorptive processes or cemental depositions that may extend well into the root canal. Histologic evidence of apical resorption on external cementum (black arrows) and layering of cementum (white arrows) into apical foramen (H&E stain 10).
  57. 57. The foreman and CDJ position on the root can be highly variable and exist anywhere from the direct radiographic apex up to 3 mm or more coronal to the radiographic apex, depending on a particular root morphology. Apical view of tooth with a C-shaped root formation. Note root morphology around the canal exits as cementum invaginates into the foramen. K-files (arrows) are exiting from the canal long before they reach the actual root surface. Actual foramina are much larger than canal exits, as indicated by widths of the red lines. Working length determination to the root length in these cases would be destructive to periapical tissue. These potential anatomic variances have had a major impact on the precise region or location for determining the working length and termination of root canal instrumentation and obturation.
  58. 58. • Prior to establishing a definitive working length, coronal access to the pulp chamber must provide a straight-line avenue into the canal orifice, thereby facilitating subsequent canal penetration. • In anterior teeth, failure to remove the lingual ledge or incisal edge often impedes this straight-line access, resulting in lack of depth penetration to the CDJ, failure to locate all canals present, or instrument penetration into the canal wall with ledge formation. • In posterior teeth, primarily molars, or multirooted premolars, failure to remove cervical ledges or bulges results in missed canals or binding of the penetrating instrument in the coronal third of the canal with ledge formation. • The ability to penetrate unimpeded to the CDJ is crucial to determining the working length of the root canal
  59. 59. • Current concepts of initial canal penetration recommend pre-flaring techniques for a coronal-to-apical approach to working length determination rather than immediate penetration to the apex region. • Emphasis is placed on straight line access to the radicular third of the canal, and considerable time and effort is spent preparing the coronal two-thirds of the root prior to apical penetration. • This eliminates coronal impingements on the working length instrument and enhances penetration to the CDJ.
  60. 60. • In curved canals, however, after obtaining straight-line access, the working length can change, especially if debris is packed around the curvature and not removed on a regular basis. • Techniques have been advocated for this purpose, and cognizant use of them is recommended. • If working length is obtained prior to straight-line access, it may be 1 mm less or even shorter after preparing the coronal two-thirds. When curves are present, as seen in the mesial buccal root, straight-line access is essential.
  61. 61. • Straight-line access eliminates the bend at the canal orifice and places the file in a more upright position closer to the reference point. • A more accurate working length will be obtained after straight-line access in the canal is established.
  62. 62. • During access opening preparation, all caries, unsupported enamel, and faulty restorations are removed in an effort to secure stable reference points as aids in working length determination. • This is especially helpful when more than one appointment is required to complete treatment. • Typical reference points are those that are closest to the file and can be identified accurately as the cleaning and shaping process develops. • If significant coronal destruction exists and extensive restorative procedures are anticipated, it is helpful to reduce unsupported tooth structure to prevent possible fracture between appointments, which may not only complicate the working length measurement already established but may also prevent associated periodontal and restorative problems should the fracture occur through the periodontal ligament.
  63. 63. • Pathologic processes resulting in apical resorption can destroy the natural constriction of the CDJ. • This will create difficulty in locating a biologically acceptable position at which to establish the working length. • The resorptive process generally produces a root end with an uneven, irregular radiographic appearance with few clues about where to prepare an apical stop. Histologic demonstration of invasive apical resorption and how it destroys the cemental-dentinal junction. Working length established at the most narrow point in the canal when invasive apical resorption is present
  64. 64. • If apical resorption presents radiographically with a scalloped or uneven proximal margin, significant three-dimensional resorption has already occurred, further complicating working length determination. • Creation of an apical stop or enhancing an apical narrowing or constriction in these situations must rely on the clinician’s judgment, drawing on experience, tactile sensation, and reliable diagnostic radiographic techniques. • If the root end is wide open from the resorptive destruction, electronic apex locators are unreliable and of little clinical value. • Consequently, the coronal-most point on the root above the resorbed apex that exhibits sound radiodensity must be identified. • This position is used as the new radiograph apex, and the working length is established 1 to 2 mm coronal to that point. • In cases of extensive irregular apical resorption, the new working length can conceivably be 5 mm or more coronal from the original root apex.
  65. 65. • A silicon stop is a common aid for evaluating the working length measurement and returning to a secure reference point. • Care must be taken to assure that the stop is placed on the file and measured at a right angle to the file. Otherwise, differences in length of a millimeter or more between files may occur, leading to either perforation and stripping of the apical foramen or inadequate cleaning and shaping of the apical seat, with corresponding loss of length. • Commercially produced stops are teardrop shaped or notched and can be positioned to indicate instrument curvature as dictated by the canal; these are essential in maintaining working length once established. • Most if not all intracanal instruments, both nickel-titanium (NiTi) and stainless steel, come with stops already positioned on their shafts.
  66. 66. Metal or silicone stoppers to mark the working length. The stopper must clearly correspond to a cusp tip and rest firmly on it. For electronic determination of working length, the silicone stopper (left) is better than a metal stopper (right) because the metal stopper can cause a short circuit.
  67. 67. Working Length Determination: Radiographic Technique • Radiography is paramount to the successful practice of endodontics during diagnosis, treatment, and postoperative evaluation. • Radiographic assessment of the tooth and periradicular structures prior to treatment will provide the clinician with essential information necessary to form a mental image of the apical complex. • The generally accepted method for establishing the working length of a root canal is to expose a periradicular radiograph with an endodontic instrument (stainless steel K-file or NiTi file) placed in the canal. • This method provides acceptable results in most instances, especially when using enhanced digital radiographic techniques in the posterior teeth.
  68. 68. Enhanced digital radiography using clear view provides a good assessment of treatment on this maxillary second molar.
  69. 69. • The primary problem focuses on the quality of the radiograph produced, which is a composite of proper film placement, tubehead angulation, exposure time, and film processing. • Attempts to read and interpret findings (e.g., position of a file tip in a root canal, angle of root curvature) from an exposed film that fails to meet accepted standards for diagnostic dental radiographs immediately alters the quality of the entire root canal treatment. • It also destroys the concept of problem solving, which is based on the step-by-step assessment process, identifying variances from accepted standards and eliminating them before the process is completed. • Using erroneous data from a nondiagnostic, unreadable, or otherwise unintelligible dental radiograph will result in additional problems during treatment, such as instrumentation beyond the end of the root, canal ledging, loss of length, and associated complications.
  70. 70. • Dental radiographs also have inherent limitations, perhaps the most important being that they provide only a two dimensional image of a three-dimensional object. • Coupled to the anatomic variability of the apical foramen and the apical constriction relative to the root end, radiographs fall far short of the ideal tool for determining the working length. • Additionally, radiographs are subject to the superimposition of normal anatomic features and pathologic changes on normal apical tooth anatomy. • The presence of a radiolucency can aid in the interpretation of a radiographic image because of the change in density it produces. • Likewise, the presence of a radiopacity such as the zygomatic arch can obscure the maxillary first and second molar apices. • This occurrence has been shown to affect 20% of the first molar apices and 42% of the second molar apices.
  71. 71. Left: This radiograph of an extracted maxillary molar shows the tip of the instrument to be within the root canal. Right: The corresponding photograph clearly shows that the instrument has exited the root tip. However, owing to the overlap of the tip by the root structure, it appears to be within the canal in the radiograph.
  72. 72. Anatomic landmarks that block the view of the root apex in determining working length. Enhanced digital and inverted view provides some additional detail but will not suffice for a properly placed and exposed radiograph.
  73. 73. • The radiograph is an indispensable part of root canal treatment, and a variety of ways have been identified to determine the working length. • In the method described by Ingle, an estimated working length is initially established by measuring from an accurate preoperative radiograph. • A file, preferably ISO size 15 or greater, is then placed to the estimated working length, and a second radiograph is exposed. • If the tip of the file is within 1 mm of the ideal location, the radiograph can be accepted as an accurate representation of the tooth length. • Other investigators have recommended reconfirming working lengths with a new radiograph if adjustments of 2 mm or more have to be made. This method usually provides acceptable especially when the pulp is inflamed yet vital.
  74. 74. • Controversies still exist, however, when the pulp is considered nonvital, especially in the presence of an obvious periapical radiolucency and/or when the patient is experiencing pain. • The success of the approach to working length determination is predicated on two things: (1) the accuracy of the radiograph exposed with the file in place in the canal, and (2) ensuring that the file does not move from its original position before it can be removed safely from the canal after examining the working length film.
  75. 75. A, Mandibular canine that has a periapical radiolucency is presumed to be nonvital. Many clinicians would subscribe to the penetration of the apical foramen and filling to the root length in these cases, claiming that healing will not occur without this approach. B, Working length is established short of the root length but at the natural constriction, and the canal is filled. C, Twelve month reexamination shows evidence of healing, and the patient is symptom free.
  76. 76. • Films exposed using a right-angle paralleling technique may result in magnification of the findings; some believe that using a paralleling device coupled with a grid for the pretreatment radiograph provides a consistent method for measurement control. • Using the bisecting-angle technique, the radiographic distance of files placed in teeth from the apical vertex was 0.7 mm shorter than the actual anatomic file position • Radiographic working length determination for single rooted teeth is usually a simple task of exposing a film that is parallel to the front surface of the x-ray tubehead. • Few if any anatomic structures are superimposed on the root in this situation, and length determination is straight forward. • With multirooted teeth, the superimposition of files on one another and the presence of anatomic structures may often impede easy assessment of the working length.
  77. 77. Simple radiographic exposures in maxillary anterior teeth at proper angles that assist in a more accurate working length determination.
  78. 78. • An often misunderstood method of radiographically assessing the working length is the buccal object rule or SLOB (same lingual, opposite buccal) rule, in which buccal or lingual anatomic structures can be placed predictably on the x-ray film. • By using this rule, individual files in the buccal and lingual roots of many anterior teeth with two canals or roots and all posterior teeth can be visualized and distinguished from each other. Applying the buccal object rule or SLOB (same lingual, opposite buccal) rule using digital radiography to determine the working length for a maxillary premolar with two divergent roots. A, Preoperative film. B, Cone position from the mesial with the beam directed distally. The buccal root is the most distally placed root.
  79. 79. • Mesial buccal and distal buccal roots of maxillary premolars and molars can be shifted to expose the palatal root, and the zygomatic arch can be displaced from molar root apices for clear viewing of working length files. Applying the buccal object rule or SLOB (same lingual, opposite buccal) rule using enhanced clear-view digital radiography to determine the working length for a maxillary premolar with two aligned roots. A, Preoperative, using digitally enhanced clear view. B, Radiograph taken with a slight distal inclination of the radiographic beam using clear view.
  80. 80. Mandibular molar working length radiograph taken with the cone angled from the mesial, with the beam going distally. • Using a parallel technique and constant reproducible angles, a slight 20- to 30-degree horizontal or vertical tubehead shift can predictably shift roots and structures to aid in accurate working length determination. • Although it takes time and experience to develop this reliable technique, once mastered it greatly simplifies working length determination by minimizing problems encountered in the interpretation of undiagnostic radiographs. • Hence the quality of root canal treatment can be enhanced.
  81. 81. Working Length Determination: Electronic Apex Locator • Electronic apex locators (EALs) have been available for almost 40 years for measuring the length of the root canal. • These instruments work on the principle that the resistance between the periodontal membrane and the oral mucosa is a constant 6.5 kilo-ohms. • More recently, the resistance-type apex locators have been superseded by impedance and frequency-type instruments which have been reported to be accurate to within 0.5 mm greater than 90% of the time. • Apex locators can be used as an adjunct in determining working lengths where problems with anatomic variations obscure visualization of the periradicular area. • In addition, they may be used to determine perforations or in patients where radiation exposure needs to be reduced.
  82. 82. • One issue of concern with EALs was their ability to work in the canal in the presence of various fluids such as blood and irrigants. • This was a problem, but most EALs have resolved this issue. • Another issue was the size of the root canal, in particular the size of the apical constriction and the use of various file sizes. • For best results, the use of a file that closely approximates the width of the constriction is recommended.
  83. 83. Working Length Determination: Other Clinical Techniques Two other techniques have been advocated for determining the working length of the root canal: (1) the use of paper points (2) tactile sensation as a small instrument is placed slowly in the canal
  84. 84. • Paper points may be helpful in determination of the canal exit if the canal can be dried of any periapical fluid. • Inflamed tissues will moisten the tip of the paper point at the level of the canal exit. • If, however, there is significant bleeding or the paper point is not made of tightly compacted paper, it may absorb a lot of blood and not provide a reasonable accurate indication of the position of the constriction. This technique is empirically based and has no scientific evidence to support its routine use.
  85. 85. • The use of tactile sensation also has the potential for significant variables, especially in light of the wide variety of apical constrictions that may occur. • The first file to bind in its apical movement may not define the constriction accurately. • To overcome this problem, initial flaring or preflaring of the canal is recommended to eliminate any false coronal interferences to instrument passage apically and enhance tactile sensation apically.
  86. 86. Digital radiographic series of a mandibular molar using the clear-view option. Pulp is vital and inflamed. A, Preoperative. B, Working length with files positioned at the natural constriction protecting the vital tissue at the root apex. Patency filing is NOT used in these cases; there is no scientific evidence to support its use. C, Obturation to the natural constriction.
  87. 87. Controversies and Challenges With the Pulpal and Periapical Status and Their Impact on Working Length Determinations and Choices • The wide range of anatomic variables and technical interpretations regarding the apical location for determining the working length have been identified. • Because the location of this variable terminal position for working length, cleaning, shaping, and obturating the root canal has resulted in significant clinical opinions, applications, and advocacies, at least two camps of polarized thought and a vast array of multiple outliers have evolved.
  88. 88. • One major philosophy is to retain all procedures within the confines of the root. • As determined by the position of the apical constriction, while the other philosophy espouses confining the determination of working length, cleaning, shaping, and obturation to the anatomic root apex or root length. • In most teeth, overlap or agreement may occur in some cases, but these two philosophies are incompatible. • In light of the controversy, there seems to be a middle-of-the-road position that most clinicians can travel comfortably and that will yield success.
  89. 89. • While the choices can vary, it would seem to be dependent on the status of the dental pulp, access to the end of the root, and the clinician’s skill, expertise, and experience that demonstrates that particular choices provide positive outcomes in the majority of cases. • However, there does not appear to be any evidence-based data at the highest level to verify this approach, and therefore it is empirically driven.
  90. 90. • If the dental pulp is vital (inflamed; irreversible pulpitis), the working length is established clinically as close to the constriction as possible, and all procedures are retained within the root canal. • This position has been advocated as approximately 1 mm from the radiographic apex, but this dictate is flawed. • The thought behind it is that the tissue that invaginates into the canal from the periodontal ligament (periodontal in nature) is not disturbed by the subsequent cleaning, shaping, and obturation accomplished within these confines. • This recommendation is based on sound wound-healing principles in that severance of the tissue at its narrowest point will create the smallest wound possible for healing. • It also encourages the potential for tissue regeneration, not just repair, with the formation of cementum as opposed to only fibrous connective tissue or persistent chronic inflammation.
  91. 91. Histologic evidence for healing at the apical foramen when intracanal procedures are maintained inside the canal (RCF, root canal filling; PDL, periodontal ligament
  92. 92. Pushing obturation materials beyond the apical constriction, with resultant periapical chronic inflammatory response (CIR). Yellow arrow shows extent of root filling and an attempt at fibrous encapsulation. NO cementum is formed (H&E stain 10; canine model, 120 days).
  93. 93. Histologic evidence for healing at the apical foramen when procedures and materials are retained in the root canal (RCF, root canal filling; C, cementum; PDL, periodontal ligament). Arrow indicates the presence of a cemental barrier that has formed from the cells of the periodontal ligament. If the filling had gone beyond the constriction, the PDL cells would not have been able to differentiate and form a new cemental layer (B&B stain 4; human specimen).
  94. 94. • If the dental pulp is nonvital (obvious necrosis; presence of a periapical radiolucency)- working length is initially established as close as possible to the canal exit or slightly short of the apical foramen to clean the entire length of the canal, thereby eradicating bacteria as much as possible and removing the substrates that could encourage bacterial regrowth and multiplication. • However, because the root apex can be highly irregular, especially in the presence of obvious or even unidentified apical resorption, files placed to the apical extent of the root as viewed radiographically will likely be outside the confines of the canal and create potential damage to the root anatomy at that point. • It is also possible that this technique may serve to inoculate the apical tissues with bacteria and material debris. • Here also, a middle-of-the-road philosophy has been proposed: clean and shape the canal to the entire length of the root, then (1) back up or retreat into the canal sufficiently to develop a constriction or (2) stop inside the root for further intracanal procedures. However, even with this choice, the movement of materials past the root apex into the periapical tissues usually cannot be prevented.
  95. 95. Maxillary lateral incisor with significant periapical bone loss. Working length determination; patency filing was NOT used. Twelve-month reexamination; healing stable but not complete. In these situations it is not uncommon to have healing with fibrous scar tissue.
  96. 96. Histologic evidence for an adverse tissue response with the expression of material beyond the confines of the root canal (RCF, root canal filling, CIR, chronic inflammatory response)
  97. 97. A. Maxillary premolar with broken post, periapical lesion, and poor root canal filling with open apex possibly due to resorption. B, Post is removed and working length is established short of the end of the root. C, Root canal filled, staying short of the resorbed apex. D, 20 months. Patient is symptom free, tooth is functional, and the periapical lesion appears to be healed.
  98. 98. Posttreatment Implications and Outcomes of Root Canal Treatment Based on Working Length Philosophies • Authors such as Grove, Blayney, Coolidge, Kronfeld, and Davis all agreed that termination of root canal procedures should occur in a manner that would allow for proper healing, that is, deposition of cementum at the root apex to secure a complete biological seal. • The ideal healing response in the periradicular tissues following root canal treatment would result in deposition of cementum over the apical foramina, with regeneration of the periodontal apparatus. • However, repair, not regeneration, is the usual outcome. • Most obturation materials available today possess no regenerative potential, having neither inductive nor conductive properties.
  99. 99. • Studies have demonstrated the negative effect of gutta-percha and calcium hydroxide on the extracellular matrix tissues and on alkaline phosphatase activity. • Therefore, it would appear logical that extrusion of obturation material beyond the confines of the root canal system will further irritate the periradicular tissues and delay healing. • Controversies will continue to surround the management of the root apex, even though contemporary root canal treatment has a high rate of clinical success. • With patients demanding a greater degree of tooth retention using modern treatment modalities, there will be continued efforts to identify an all-compassing technique and material to achieve the goals of successful treatment on a predictable basis. • These expectations can only be achieved by establishing an evidenced-based and problem-solving approach to treatment that reflects a biological basis for the therapy rendered.
  100. 100. References • ENDODONTICS- Vol 1- Arnaldo Castelucci • Problem solving In Endodontics- 5th edition- Guttmann, Lovdahl • Cohen’s Pathways of the Pulp- 10th edition • Ingle ENDODONTICS- 6th edition • Textbook of endodontics- Nisha Garg- 2nd edition • ENDODONTOLOGY- Baumann, Beer • Electronic apex locators- A REVIEW. M. P. J. Gordon & N. P. Chandler. International Endodontic Journal, 37, 425–437, 2004 • Comparision between radiographic and electronic working length determination in root canal treatment in vivo study. Zahid Iqbal , Rafique Ahmed Memon. ISRA MEDICAL JOURNAL Volume 5 Issue 1 Mar 2013 • Current Challenges and Concepts in the Preparation of Root Canal Systems: A Review. Ove A. Peters. JOE, VOL. 30, NO. 8, AUGUST 2004 • Apical constriction: A cell shape change that can drive morphogenesis. Jacob M. Sawyer, Jessica R. Harrell, Gidi Shemer, Jessica Sullivan-Brown, Minna Roh-Johnson, Bob Goldstein Developmental Biology 341 (2010) 5– 19 • An in vivo study to evaluate the efficacy of electronic apex locators in the determination of working length. Fahad Qiam, Khalid Rehman, Bushra Mehboob, Muhammad Kamran. JKCD June 2011, Vol. 1, No. 2 • Intricate internal anatomy of teeth and its clinical significance in endodontics - A review. A.P. Tikku, W. Pragya Pandey, Ivy Shukla. ENDODONTOLOGY

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