SEMINAR PRESENTATION - 11

ENDOMETERICS
Root canal working length determination

Date – 14-04-06

Presented by
Dr. Anantkumar A. Heda
(Post-Graduate Student)
DEPARTMENT OF
CONSERVATIVE DENTISTRY AND ENDODONTICS,
RURAL DENTAL COLLEGE, LONI
 Contents

 Introduction

 Anatomic considerations & Terminologies used

 Historical perspectives

 Clinical considerations

 Methods / Classification

Radiographic methods

Digital tactile sense

Electronic methods

Apical periodontal sensitivity

Paper point measurements

 Summary

 Conclusion

 References
 Introduction

A successful root canal therapy depends upon thorough cleaning and

shaping. This step can be accomplished after determining accurate working
length.
Therefore, determination of an accurate working length is one of the
most critical steps in endodontic therapy

Significance

 The calculation determines how far into the canal the instruments are
placed and worked and thus how deeply into the tooth the tissues, debris,
metabolites, end products, and other unwanted items are removed from the
canal
 Hence, successful endodontic treatment – dependant upon the ability to
accurately determine the length of root canal system – that will facilitate
proper shaping, cleaning and obturation
 Limit the depth to which the canal filling may be placed
 It will affect the degree of pain and discomfort that the patient will feel
post-operatively
 If calculated within correct limits – play an important role in determining
success of the treatment.
 Conversely, if calculated incorrectly may doom the treatment to failure.
 Wrong working length estimation could lead to –
 Enlarged foramen & its attendant sequelae
 Periapical irritation & inflammation
 Loss of control during obturation
 Preparation short can lead to –
 Accumulation of debris (focus of infection)
 Ledge formation
 Therefore, calculation of working length should be performed with
 skill
 using techniques that have proven to give valuable and accurate results &
 By methods that are practical and efficacious.
 Produce treatments of high quality and considerable longevity
Anatomic considerations & Terminologies used
 Simon (1994) has stressed the need for clarification and consistency in the
use of terms related to working length determination.
 Working length - defined in the endodontic Glossary as “the distance
from a coronal reference point to the point at which canal preparation and
obturation should terminate (the ideal apical reference point in the canal, the
“apical stop”)”
 The anatomic apex - the tip or the end of the root determined
morphologically, whereas
 The radiographic apex - the tip or end of the root determined
radiographically.
 Root morphology and radiographic distortion may cause the location of the
radiographic apex to vary from the anatomic apex
 The apical foramen – the main apical opening of the root canal.
 It is frequently eccentrically located away from the anatomic or
radiographic apex.
 Extensive study of Kuttler (1955) showed that this deviation occurred in 68
to 80% of teeth in his study.
 Most commonly the foramen opens 0.75 to 1mm short of the root tip.
 However, the canal may even exit 3 mm short of the apex.
 An accessory foramen is an orifice on the surface of the root
communicating with a lateral or accessory canal.
 They may exist as a single foramen or as multiple foramina.
Care should be exercised to establish the position of the foramen. Hopefully,
it appears at the apex, and 0.5 to 1.0 mm is simply subtracted from that tooth
length as a safety factor. The lateral exit of the canal (right) can sometimes
be seen in radiograph or discovered by instrument placement and re-
examined radiographically.Even the patient’s reaction to the instrument is a
warning of “early exit,” especially toward the labial or lingual unseen in the
radiograph
 The apical constriction (minor apical diameter) – the apical portion of the
root canal having the narrowest diameter.
 This position may vary but is usually 0.5 to 1.0 mm short of the center of
the apical foramen.
 The minor diameter widens apically to the foramen (major diameter) and
assumes a funnel shape.
Diagrammatic view of the
periapex.
The importance of
differentiating between the
minor diameter (apical stop)
and the major diameter
(radiographic apex) is apparent
 The cementodentinal junction – the region where the dentin and
cementum are united, the point at which the cemental surface terminates at
or near the apex of a tooth.
 However, the CDJ - a histologic landmark that cannot be located clinically
or radiographically.
 Langeland reported that the cementodentinal junction does not always
coincide with the apical constriction.
 The location of the CDJ ranges from 0.5 to 3.0 mm short of the anatomic
apex.
 Therefore, it is generally accepted that the apical constriction is most
frequently located 0.5 to 1.0 mm short of the radiographic apex, but with
variations.
 Theoretically, the canal preparation and, thus, the canal filling should
terminate at the cemento-dentinal junction.
 CDJ – histologic site - In the clinical settings, it is impossible to locate it –
therefore, methods must be applied to ascertain this critical position.
 Historical perspectives

 The early days of endodontic treatment – end of 19 th century – radiographs

had not yet been applied to dentistry
 working length was usually calculated t the site where the patient
experienced the feeling for an instrument placed into the canal – led to
multiplicity of errors
 If vital tissue – left in the canal unextirpated – the resultant calculation –
too short
 If a periapical lesion – present – too long calculation
 Teeth with more than one canal in a root could also give inaccurate
information
 With the advent of application of X-rays to dentistry – by Kells in 1899 –
teeth were treated without the benefit of radiographs, but evaluated by dental
films which indicated such miscalculations

 In early portion of the 1900's, popular belief was that the pulp extended
through the tooth, past the apical foramen into the periapical tissue and that
the narrowest diameter of the apical portion of the root canal is precisely at
the site where the canal exits the tooth at the extreme apex.

 These views fostered the then- prevailing technique to calculate to the tip
of the root on radiograph i.e. the RADIOGRAPHIC APEX.
 Thus, the radiogrqphic apex replaced the feeling of the patient as the apical
position for working length calculation.
 Grove (1920) concluded – pulp tissue could not extend beyond the CDJ
because the cells unique to the dental pulp, the odontoblasts were not found
beyond the CDJ
 Hatton & Grove advised – preparation beyond the CDJ would result in
injury to the periapical tissues

 Blayney & Coolidge – through cases and histologic evaluations – indicated

that filling slightly short of the root tip – best results

 Kuttler (1955) – most comprehensive anatomic microscopic study of the

root tip (several thousands root teeth under light microscope) – detailed
anatomic description of the root tip – verified by many others later.

 According to Kuttler, the narrowest diameter of the canal is definitely not

at the site of exiting of the canal from the tooth – but usually occurs within
the dentin, just prior to the initial layers of dentin – referred – minor
diameter

 The diameter of the canal at the site of exiting – major diameter – approx.
twice as wide as minor diameter
 The average distance between the minor diameter (apical constriction) and
the major diameter (apical foramen) –
 0.524mm in 19-25 year old
 0.659mm in 55 years and above

 Longitudinal view of the canal as a tapering funnel – incorrect

 The funnel tapers to a distance short of the site of exiting and then widens
again
 The configuration of the area between the minor and major diameters
resembles – morning-glory flower
 This morning-glory flower configuration – often clearly visualized when
sealer – slightly extruded
 Clinical considerations

 Before determining a definitive working length, the coronal access to

the pulp chamber must provide a straight line pathway into the canal orifice.
 Modifications in access preparation may be required to permit the
instrument to penetrate, unimpeded, to the apical constriction.
 As stated above, a small stainless steel K file facilitates the process and
the exploration of the canal.
 Loss of working length - frustrating procedural error.
 Once the apical restriction is established, it is extremely important to
monitor the working length periodically - since the working length may
change as a curved canal is straightened
 “a straight line is the shortest distance between two points”
 The mean shortening of all canals in studies was found to range from
0.40 mm to 0.63 mm.

 The loss may also be related to

-the accumulation of dentinal and pulpal debris in the apical 2 to 3 mm of
the canal or
- other factors such as failing to maintain foramen patency, skipping
instrument sizes, or failing to irrigate the apical one-third adequately.
-Occasionally, working length is lost owing to ledge formation or to
instrument separation, and blockage of the canal.
 Failure to accurately determine and maintain working length may result
in the length being too long - may lead to
-Perforation through the apical constriction
-Overfilling or overextension
-Increased incidence of postoperative pain
-Prolonged healing period
-Lower success rate owing to incomplete regeneration of cementum,
periodontal ligament, and alveolar bone

 Failure to accurately determine and maintain working length may also

lead to shaping and cleaning short of the apical constriction.
-Incomplete cleaning and underfilling may cause
- persistent discomfort
-an incomplete apical seal
-apical leakage may occur into the uncleaned and unfilled space short of
the apical constriction
-Such leakage supports the continued existence of viable bacteria and
contributes to a continued periradicular lesion and
-lowered rate of success

Reference points
 Any measurement of length refers to the distance between two points.
 One point of the measurement of the working length refers to the end point
of the preparation, the other point may vary considerably.
 The measurement should be made from a secure reference point on the
crown, in close proximity to the straight-line path of the instrument, a point
that can be identified and monitored accurately.
 A definite, repeatable plane of reference to an anatomic landmark on the
tooth – necessary.
 It is essential to record the reference point and the working length of each
instrument in the patient’s chart.

 Coronal reference point on the tooth –

-For anterior teeth - Incisal edge or adjacent teeth or some projecting
portion of the remaining tooth structure
-For 2 canal premolars – buccal canal: buccal cusp tip, palatal canal:
either cusp tip
-For molars – cusp tips
Marginal ridge of adjacent tooth
at the cavo-incisal or cavo-occlusal angle

 It is imperative that teeth with fractured cusps or cusps severely

weakened by caries or restoration be reduced to a flattened surface,
supported by dentin.
 Failure to do so may result in cusps or weak enamel walls being fractured
between appointments
 Thus, the original site of reference is lost. If this fracture goes
unobserved, there is the probability of over-instrumentation and overfilling,
particularly when anesthesia is used.
A- Do not use weakened enamel walls or diagonal lines of fracture as a
reference site for length-of-tooth measurement.
B- Weakened cusps or incisal edges are reduced to a well-supported tooth
structure. Diagonal surfaces should be flattened to give an accurate site of
reference.

Stop Attachments –
 A variety of stop attachments are available.
 Least expensive and simplest to use - silicone rubber stops.
 Several brands of instruments are now supplied with the stop attachments
already in place on the shaft.
 Special tear-shaped or marked rubber stops can be positioned to align
with the direction of the curve placed in a precurved stainless steel
instrument.
 The length adjustment of the stop attachments should be made against the
edge of a sterile metric ruler or a gauge made specifically for endodontics.
 Devices have been developed that assist in adjusting rubber stops on
instruments.
 It is critical that the stop attachment be perpendicular and not oblique to
the shaft of the instrument

Left, Stop attachment should be placed perpendicular to the long axis of the
instrument. Right, obliquely placed stop attachment varies the length of
tooth measurement by over 1mm.

 Disadvantages of using rubber stops

-time consuming,
-rubber stops may move up or down the shaft, which may lead to
preparations short or past the apical constriction.

 Instruments have been developed with millimeter marking rings etched

or grooved into the shaft of the instrument.
 These act as a built-in ruler with the markings placed at 18, 19, 20, 22,
and 24 mm.
 With these marking rings, the best coronal reference point on the tooth is
at the cavo-incisal or cavo-occlusal angle.
 These marking rings are necessary when rotary nickel titanium
instruments are used.
The requirements of an ideal method for determining WL
include (Ingle)–

 rapid location of the apical constriction in all pulpal conditions and all
canal contents;
 easy measurement, even when the relationship between the apical
constriction and the radiographic apex is unusual;
 rapid periodic monitoring and confirmation;
 patient and clinician comfort;
 minimal radiation to the patient;
 ease of use in special patients such as those with severe gag reflex, reduced
mouth opening, pregnancy etc; and
 cost effectiveness.
 To achieve the highest degree of accuracy in working length determination,
a combination of several methods should be used.
 Methods / Classification

Grossman – radiographic method

electronic method
Ingle –
The most common methods are
 radiographic methods,
 digital tactile sense, and
 electronic methods.
 Apical periodontal sensitivity and
 Paper point measurements have also been used.

Weine –
Currently, there are 4 major, specific methods for calculation of WL i.e. 4
methods have enough adherents
1. Radiographic apex – filling to the tip of the root as seen on the x-ray film
2. A specific distance from the radiographic apex
3. According to the studied of Kuttler
4. Use of an electronic apex locator

Radiographic –
 Grossman’s method
 Other formula based methods
 Ingle’s method
 According to Kuttler’s studies
  Wire Grid method
Non-radiographic –
 Using digital tactile sense
 Apical periodontal sensitivity
 Paper point evaluation
 Electronic methods: based on resistance, impedance, frequency

Determination of Working Length by digital tactile sense

 Earliest method
 Although it may appear to be very simple, its accuracy depends on
sufficient experience.
 The clinician should be able to literally feel the foramen by tactile sense.
 Confirmation may be done either by the radiographic or electronic method.
 If the coronal portion of the canal is not constricted, an experienced
clinician may detect an increase in resistance as the file approaches the
apical 2 to 3 mm.
 In this region, the canal frequently constricts (minor diameter) before
exiting the root. There is also a tendency for the canal to deviate from the
radiographic apex in this region
 An accuracy of just 64% (Seidberg et al, 1975)
 Another in vivo study found that the exact position of the apical
constriction could be located accurately by tactile sense in only 25% of
canals (Bal & Chaudhary, 1989)

 If the canals were preflared, it was possible for an expert to detect the
apical constriction in about 75% of the cases. (Stabolz et al, 1995)
 If the canals were not preflared, determination of the apical constriction
by tactile sensation was possible in only about one-third of the cases.
(Ounsi & Haddad, 1998)
 Method – often inexact.
 Ineffective in root canals with an immature apex and is highly inaccurate if
the canal is constricted throughout its entire length or if the canal has
excessive curvature.
 This method should be considered as supplementary to high-quality,
carefully aligned, parallel, working length radiographs and/or an apex
locator.

 Determination of Working Length by Apical periodontal sensitivity

 Any method of working length determination, based on the patient’s
response to pain, does not meet the ideal method of determining WL
 WL determination should be painless.
 Endodontic therapy has gained a notorious reputation for being painful,
and it is incumbent on dentists to avoid perpetuating the fear of endodontics
by inserting an endodontic instrument and using the patient’s pain reaction
to determine working length.
 If an instrument is advanced in the canal toward inflamed tissue, the
hydrostatic pressure developed inside the canal may cause moderate to
severe, instantaneous pain.
 At the onset of the pain, the instrument tip may still be several millimeters
short of the apical constriction.
 When pain is inflicted in this manner, little useful information is gained by
the clinician, and considerable damage is done to the patient’s trust
 When the canal contents are totally necrotic, however, the passage of an
instrument into the canal and past the apical constriction may evoke only a
mild awareness or possibly no reaction at all. The latter is common when a
periradicular lesion is present because the tissue is not richly innervated.
 any response from the patient, even an eye squint or wrinkling of the
forehead, calls for reconfirmation of working length by other methods
available and/or profound supplementary anesthesia.

Determination of Working Length by Paper Point Measurement

 In a root canal with an immature (wide open) apex, the most reliable
means of determining WL is to gently pass the blunt end of a paper point
into the canal after profound anesthesia
 The moisture or blood on the portion of the paper point that passes beyond
the apex - an estimation of WL or the junction between the root apex and the
bone.
 In cases in which the apical constriction - lost owing to resorption or
perforation, and in which there is no free bleeding or suppuration into the
canal, the moisture or blood on the paper point is an estimate of the amount
the preparation is overextended.

 This method, however, may give unreliable data –

-If the pulp not completely removed
-If the tooth – pulpless but a periapical lesion rich in blood supply present
-If paper point – left in canal for a long time

 This paper point measurement method is a supplementary one.

  Paper points with the addition of millimeter
markings – These paper points have markings
at 18, 19, 20, 22, and 24 mm from the tip – can
be used to estimate the point at which the it
passes out of the apex.
 The accuracy of these markings should be
checked on a millimeter ruler

Determination of Working Length by Radiographic methods

 Historically & traditionally, the method of choice for determination of
working length of the tooth is radiography.
 The techniques and calculations - more or less vary - but the basic
procedure of taking radiographs of the tooth with a radiopaque instrument
extending into the canal - same
 The radiograph plays an important role in endodontics because – permits
the operator to form a visual conception of the internal tooth structure and
periradicular tissue.
 The radiograph – an exact ‘road map’ of the anticipated journey between
the access opening into the pulp chamber and the apical root foramen
 The clinician must learn to interpret the radiograph
 Radiographs are helpful –
 To measure the length between two reference points
 Avoid inadvertent perforations
 To note presence of atypical anatomy
 The number of canals and roots
 Curvatures, bifurcations, lateral canals, pulp stones,
 Obstructions such as root canal fillings, posts, or broken instruments
 Resorptions, decay, and periodontal disease
Grossman’s method
 Grossman (1970, 7th ed.) gave the following formula for determining
the correct length of the tooth –
rule of proportion basis
 CLT = KLI × ALT / ALI Where,
CLT= correct length of the tooth
KLI= known length of the instrument in the tooth
ALT= apparent length of the tooth on radiograph
ALI= apparent length of the instrument on radiograph

A, The length of the tooth is measured on the diagnostic radiograph (schematic view).
B, This measurement is transferred to a diagnostic instrument prepared with a silicone
stop, the instrument is placed in the root canal, and a radiograph is made.
C and D, The root canal and working lengths are determined from the radiograph.

 However, it is suggested that the working length should be arbitrarily

established 0.5 to 1.0 mm shorter than the measured canal length (because
the actual length of the tooth is 1.2 mm less than the radiographic image and
the apical foramen is approx. 0.3 mm short of the actual root tip)
 When apical resorption – evident on a radiograph, WL should be reduced
by 1.5 to 2.0 mm
Other formula based methods
 Bregman (1950) – devised a method – 25 mm length flat probes –
having a steel blade fixed with acrylic resin as a stop leaving a free end of
10mm for placement into the root canal.
 This probe is placed in the tooth until the metallic end touches the
coronal reference point.
 A radiograph is taken
 The length is calculated from following formula:

Actual length of the tooth = Real instrument Length × Apparent length of tooth
Apparent Instrument Length

 Best (1960) – fixed a 10 mm metal wire to the outer lingual surface of the
tooth with utility wax keeping it parallel to the long axis. After the film is
exposed and processed, the length is determined with the help of a special
ruler
 Bramnate (1974) – used st. steel probes of various calibres and lengths –
bent at one end at a right angle – this bend inserted partially in acrylic resin
such that its internal face flush with the resin surface contacting the tooth
surface – The probe introduced into the canal so that the resin touches the
incisal edge or cusp tip & radiograph taken

 The reference points are as follows

-Point of internal angle of intersection of incisal and radicular probe
segments
-Apical end of probe
-Tooth apex
 Tooth length calculated in two different ways –
a. Measuring radiographic probe length – AB, radiographic tooth length –
AC, and the real length of the probe and applying following equation -

Real tooth length═ Real Probe Length × Radiographic tooth length

Apparent Length of Probe on radiograph

b. Measuring the distance between the apical end of probe (B) and tooth
apex (C), and adding or subtracting to obtain the correct length of the tooth.

 Poster by a PG at 19th FODI & 12th IES National conference, Bangalore –

presented a formula for WL as follows:
 First calculate
% distortion(D) = Actual length of Instrument (L) x 100
radiographic length of Instrument
2. Actual length of tooth (if instrument overextended) = L – [length of
extended portion of instrument on radiograph] x D / 100
3. Actual length of tooth (if instrument short) = L + [remaining length to
which instrument has to be extended on radiograph] x D / 100
4. Working length = A – 1 mm

Wire grid method

 Everett and Fixot (1963) – introduced the diagnostic x-ray grid for use
with paralleling technique
 This wire grid has lines running 1 mm apart, lengthwise and cross wire
 Every 5th mm is accentuated by a heavier line – to facilitate reading
 The grid – taped to the film and lies between the object and the film so
that the image of grid is incorporated in the film
 Tooth length can be read directly from the preoperative radiograph with
the aid of a special calibrated ruler

 Larhein & Eggen (1979) – determined tooth length with a standardized

paralleling technique and calibrated radiographic measuring film
 The measuring grid was conveyed to the film as a latent pattern by a
stencilling process prior to the x-ray exposure.
 The distance between the measuring lines was adjusted in accordance
with image magnification
 The length of the tooth is read directly on the finished radiograph

 Paper presented by a PG at 6th national PG convention at Chennai

discussed about non metallic radiographic grids
 Used materials were –
 Radiographic film
 Canvas material – cut to the film size and stuck to film using a tape
 Thin double-sided adhesive tape
 Radiopaque dye
 Plastic sleeve
 0.3 ml of radiopaque dye spread over the canvas and the film is inserted
into a plastic sleeve – film exposed and processed as usual
 The final radiograph – normal anatomical landmarks with 1 mm square
radiopaque lines
 Advantages – easiness, feasibility, economical, user friendly
Ingle’s method
 Methods requiring formulas to determine working length have been
abandoned.
 Bramante and Berbert reported great variability in formulaic
determination of working length, with only a small percentage of successful
measurements.
 The radiographic method known as the Ingle Method proved to be
“superior to others”
 It showed a high percentage of success with a smaller variability.
 This method, first proposed more than 40 years ago, has withstood the
test of time and has become the standard as the most commonly used
method of radiographic working length estimation.

 The following items are essential to perform this procedure:

1. Good, undistorted, preoperative radiographs showing the total length
and all roots of the involved tooth.
2. Adequate coronal access to all canals.
3. An endodontic millimeter ruler.
4. Working knowledge of the average length of all of the teeth.
5. A definite, repeatable plane of reference to an anatomic landmark on
the tooth, a fact that should be noted on the patient’s record.

 To establish the length of the tooth, a stainless steel reamer or file with an
instrument stop on the shaft is needed. The exploring instrument size must
be small enough to negotiate the total length of the canal but large enough
not to be loose in the canal. A loose instrument may move in or out of the
canal after the radiograph and cause serious error in determining the length
of tooth.
 Moreover, fine instruments (Nos. 08 and 10) are often difficult to see in
their entirety in a radiograph, as are nickel-titanium instruments.
 In a curved canal, a curved instrument is essential.

Method
1. Measure the tooth on the preoperative radiograph
2. Subtract at least 1.0 mm “safety allowance” for possible image distortion
or magnification.
3. Set the endodontic ruler at this tentative working length and adjust the
stop on the instrument at that level
4. Place the instrument in the canal until the stop is at the plane of reference
unless pain is felt (if anesthesia has not been used), in which case, the
instrument is left at that level and the rubber stop readjusted to this new
point of reference.
5. Expose, develop, and clear the radiograph
6. On the radiograph, measure the difference between the end of the
instrument and the end of the root and add this amount to the original
measured length the instrument extended into the tooth. If, through some
oversight, the exploring instrument has gone beyond the apex, subtract this
difference.
7. From this adjusted length of tooth, subtract a 1.0 mm “safety factor” to
conform with the apical termination of the root canal at the apical
constriction
8. Set the endodontic ruler at this new corrected length and readjust the stop
on the exploring instrument
9. Because of the possibility of radiographic distortion, sharply curving
roots, and operator measuring error, a confirmatory radiograph of the
adjusted length is highly desirable.
10.When the length of the tooth has been accurately confirmed, reset the
endodontic ruler at this measurement.
11. Record this final working length and the coronal point of reference on
the patient’s record.
12. Once again, it is important to emphasize that the final working length
may shorten by as much as 1 mm as a curved canal is straightened out by
instrumentation.
It is therefore recommended that the “length of the tooth” in a curved canal
be reconfirmed after instrumentation is completed.
Weine’s modification -
 If, radiographically, there is no resorption of the root end or bone, shorten
the length by the standard 1.0 mm.
 If periapical bone resorption is apparent, shorten by 1.5 mm, and
 if both root and bone resorption are apparent, shorten by 2.0 mm
 The reasoning - If there is root resorption, the apical constriction is
probably destroyed—hence the shorter move back up the canal. Also, when
bone resorption is apparent, there probably is also root resorption, even
though it may not be apparent radiographically.

Weine’s recommendations for determining working length based on

radiographic evidence of root/bone resorption. A, If no root or bone
resorption is evident, preparation should terminate 1.0 mm from the apical
foramen. B, If bone resorption is apparent but there is no root resorption,
shorten the length by 1.5 mm. C, If both root and bone resorption are
apparent, shorten the length by 2.0 mm.
Variations.
 When the two canals of a maxillary first premolar appear to be
superimposed, it is advantageous to take individual radiographs of each
canal with its length-of-tooth instrument in place.
 A preferable method is to expose the radiograph from a mesial-horizontal
angle. This causes the lingual canal to always be the more mesial one in the
image (MLM, Clark’s rule) or, alternatively, MBD—when the x-ray beam is
directed from the Mesial, the Buccal canal is projected toward the Distal on
the film.
 When a mandibular molar appears to have two mesial roots or apices of
different lengths or positions, two mesial instruments can be used, and again
the tooth can be examined radiographically from the mesial and Clark’s or
Ingle’s rule (MLM or MBD) applied.

Methods to separate images of canals are-

- Taking separate films with one file in place per film – time consuming
, more exposure
- Identifying specific canals by using a reamer in one canal and file in
the other
- Using a larger instrument in one canal and a smaller instrument in the
other

Weine’s Method (based on Kuttler’s studies)

 The basis for this method’s value is the measurements provided by
Kuttler relating to the distance between the major & minor diameters.
 In younger patients, the distance between these two positions – approx.
0.5 mm
 In older patients, due to increased buildup of cementum, the distance –
approx. 0.67 mm
 The method given by Weine based on Kuttler’s measurements is as
follows - Before starting endo. t/t – analyze C-L-E-W
 Identify the probable canal Configuration and any common variants
 The estimated Lengths of the root(s)
 The site of Exiting the canal(s)
 The estimated Width of the canal(s)
C-L-E-W - by analyzing the pre-operative radiographs –
straight (for site of exit, root length, canal width) and
angled views (for canal configuration, site of exit, no. of roots and canals)

Stepwise technique –
1. Prepare correct access cavity – using the information from the straight
and angled radiographs. Remove whatever pulp tissue or debris that one
believe should be removed
2. Locate major diameter or minor diameter on the pre-operative radiograph
3. Estimate the length of the root(s), by measuring the length with a
millimeter ruler on the preoperative radiographs (without projection, but
may use magnification)
4. Estimate the width of the canal(s) on the radiographs. Choose an
appropriate fitting file.
5. Using the file selected by step 4, set the stop for the working length
according to the measurement estimated in step 3. place the file and take
an initial radiograph.
6. If the file appears too long or too short by more than 1 mm from minor
diameter, make the interpolation (correction), adjust the file accordingly,
and retake the film to verify accuracy.
7. If the file appears too long or too short by less than 1 mm from minor
diameter, make the interpolation (correction) and use that as the
calculated WL
8. If file reaches the major diameter exactly, subtract 0.5 mm from that
length if the patient is 35 years old or younger or 0.67 mm from that
length if the patient is older. If the file reaches the site that you believe is
exactly at the minor diameter, use that as the calculated working length

Use of radiographic apex as Termination point?

 Weine - aspects of use of radiographic apex as Termination point.
 He discussed – there still remain a number of excellent clinicians –
proponents. E.g. graduates of the endodontic program at Boston
University and their disciples are most active proponents of this
technique.
 Concept – it is impossible to locate the CDJ clinically, and the
radiographic apex is the only reproducible site available
 Calculate the length of the tooth to the radiographic apex – keep this
distance patent – use larger file a bit shorter – most ideal preparation
developed as stated
 Weine further discussed that - A patent root tip and larger files kept
within the tooth body may be excellent treatment, but filling to the
radiographic apex can be only one thing – IT IS TOO LONG!!
 Decrease in success rate, postoperative pain, undesirable tear drop shape
prepared at apex amenable to seal
Advantages of radiographs
 It is an accurate road map between access opening and apex provided -
proper angulation & technique are employed and – interpreted correctly
 Easy to use
 The use of high speed films and automatic processing techniques – also
lessened the time required

Disadvantages of radiographs
 Radiation hazards patients as well as operator
 Probably time consuming
 Loss of bucco-lingual details
 If rubber dam in place – taking radiograph becomes difficult
 Gag reflex
 Observer bias

Expanded radiographic paradigms for

Determination of Working Length
 Xeroradiography
 Digital image processing
 Radiovisiography
Xeroradiography
 Xeroradiography – an electrostatic imaging system – that uses a
uniformly charged x-ray sensitive selenium alloy photoreceptor plate in a
light-proof cassette.
 When exposed to x-rays, the charge on the photoreceptor plate –
dissipated according to tissue density
 A latent electrostatic image produced
 This latent image then transformed into a visible image by deposition of
specially pigmented particles
 The visible image – transferred to a base sheet – that can be viewed either
by reflected light or a trans-illuminated light
 Cassettes are available in sizes corresponding to periapical film – 3mm
thick, and can be used with a standard intra-oral holder

Advantages:

Produces image of superior quality – edge enhancement property and
sharper contrast

Radiation levels are reduced to only 1/3rd

Rapid – require only 20 sec to produce a permanent dry image

Economical – as photoreceptor plate are reusable, can be reconditioned,
recharged and reused more than 1000 times

Processing do not require dark room

No shelf life deterioration
Disadvantages:
 Large areas of bone > 2 cm are shown better with conventional intra oral
film technique than with xeroradiography
 Greater degree of artefacts than in conventional technique
Digital image processing
 The development of this type of image analysis methodology enables
radiographs to be digitized and manipulated electronically.
 A high quality video camera with a resolution of 525 lines pairs per
frame, an analog to digital converter paired to a digital frame buffer, and
a computer form the basis of the hardware needed for this type of
processing.
 Radiographs taken using conventional techniques and processing – then
backlit and digitized, and the image area or pixels are converted to 256
gray levels.
 The gray level of each pixel is balanced to the average optical density in
the related area in the radiograph.
 Additional radiographs taken over time are digitized in the same manner
as described here.
 The subtraction technique allows normal anatomic structures to be
cancelled and any changes typically pathologic are displayed as the
subtraction image
 The technique is superior to conventional radiography for detecting
cancellous and cortical bone changes, as well as being able to detect
these changes sooner in both types of bone.
 Because the subtraction image can be manipulated electronically, it is
possible to "remove" bone traqeculae' and enhance the remaining image,
typically tooth.
 This enables the clinician to visualize tooth anatomy that would be
difficult to capture by conventional radiographic means.
 Subsequently, diagnostic and working, films can be manipulated by this
system and then stored electronically for immediate recall.

RadioVisioGraphy (RVG)
 This system is comprised of three main components:
 Radio portion - a conventional x-ray head connected to microprocessor -
enables the unit to produce short radiation exposure times. Instead of a
conventional silver halide-based film, the receptor is a sensor that
consists of a scintillation screen, a fibre optic instrument, and a charged
coupling device imaging system.
 Visio section holds the signal - then converts it by unit area into 256
shades of gray
 Graphy portion of the system is a storage module that can be connected
to a final imaging display. The module also can store the image
electronically.
 As the image is stored, it is possible to enhance it, stretch it and subject it
to negative-positive conversion.
 Additionally, the operator has the ability to zoom in on a section of the
image e.g. the apical third.
 The finial image can be printed out using thermal paper or stored
electronically for future retrieval.
 Although the resolution decreases with increasing zoom, the ability of
the unit to provide magnification is especially useful in endodontics
because it allows good visualization.
 Typical radiation doses can be upto 75% lower
 than those in conventional radiography.
Determination of Working Length by Electronic methods
 Electronic apex locator (EAL) – Most important advancement in the
recent decade - Advancement in microchip technology
 In today’s practice - one of the most important and essential instrument in
endodontic practice
 These devices all attempt to locate the apical constriction, the cemento-
dentinal junction, or the apical foramen.
 Correct use of EAL always identifies the root end correctly
 Precision needed to minimize intervisit flare-ups, over-fillings or under-
fillings
 Use of EAL – pain-free treatments, rare flare-ups and long term healing
success
 Apical constricture of the root (recommended apical limit of WL)– not
coincide with anatomic apex
 Deviated mesio-distally or linguo-buccally from the root
 Very difficult to locate accurately the position of apical foramen using
only radiographs
 The Electronic apex locator (EAL) – attracted a great deal of interest
 EAL – one of the breakthroughs that brought electronic science into
traditional endo.
 Currently EALs – used as an important adjunct to radiography to
determine the working length
 EALs help to reduce the treatment time & the radiation dose
 Custer (1918) – first to report the use of electric current to determine
working length
 The scientific basis for apex locators originated with research conducted
by Suzuki (1942) – reported a device that measured the electrical
resistance between the PDL and the oral mucosa of dogs– discovered
that the electric resistance between instrument inserted into the RC and
electrode applied at OMM registered a constant Value of 6.5 KΩ.
 In 1960, Gordon was the second to report the use of a clinical device
for electrical measurement of root canals
 Sunada (1962) – adopted the principle reported by Suzuki and was the
first to describe the detail of a simple clinical device to measure working
length in patients.
 He used a simple direct current ohmmeter to measure a constant
resistance of 6.5 kiloohms between oral mucous membrane and the
periodontum regardless of the size or shape of the teeth.
 The device used by Sunada in his research became the basis for most
apex locators.
 1973 – Inoue – reported a modification – used an audiometric
component that permitted the device to relate the canal depths to the
operator via low frequency audible sounds e.g. Sono-Explorer (Union
Broach, NY), Neosono (Amadent, NJ)
 1987 – Huang – reported this is not a biologic characteristic, but a
physical principle.

Basic principle
 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 lip or by an electrode held in the patient’s hand.
 The electrical circuit is complete when the endodontic instrument is
advanced apically inside the root canal until it touches periodontal tissue
 The display on the apex locator indicates that the apical area has been
reached.

Classification and Accuracy of Apex Locators

 First-generation apex locators – based on Resistance
 Second-generation apex locators – based on Impedance
 Third-generation apex locators – based on Frequency

First-Generation Apex Locators

 First-generation apex location devices, also known as resistance apex
locators
 Measure opposition to the flow of direct current or resistance.
 When the tip of the reamer reaches the apex in the canal, the resistance
value is 6.5 kilo-ohms (current 40 mA)
 often yield inaccurate results in presence of electrolytes, excessive
moisture, vital pulp tissue, exudates, blood

Second-Generation Apex Locators.

 Second-generation apex locators, also known as impedance apex locators
 measure opposition to the flow of alternating current or impedance
 Inoue developed the Sono-Explorer – one of the earliest of the second-
generation apex locators
 Uses the electronic mechanism that the highest impedance is at the apical
constricture where impedance changes drastically
 The Apex Finder (Sybron Endo/Analytic; Orange, Calif.)
 The Endo Analyzer (Analytic/Endo; Orange, Calif.) - combined apex
locator and pulp tester
 The Digipex (Mada Equipment Co., Carlstadt, N.J.)
 The Digipex II
 The Exact-A-Pex (Ellman International, Hewlett, N.Y.)
 The Foramatron IV (Parkell Dental, Farmingdale, N.Y.)
 The Pio (Denterials Ltd., St. Louis, Mo.)

Disadvantages – The major disadvantage of second-generation apex

locators the root canal has to be reasonably free of electro-conductive
materials to obtain accurate readings.
 The presence of tissue and electro-conductive irrigants in the canal
changes the electrical characteristics and leads to inaccurate, usually
shorter measurements.
 This created an awkward situation – Should canals be cleaned and dried
to measure working length, or should working length be measured to
clean and dry canals?
 Large files coated with Teflon to be used – difficult to use in narrow
canals, Teflon peeled off in curved canals
 Patient discomfort due to high current used
 Calibration had to be done before every use

Third-Generation Apex Locators.

 Frequency dependant apex locators –
 Introduced in 1990s
 Uses more advanced technology & measures the impedance difference
between the two frequencies or the ratio of two electrical impedances
 Since the impedance of a given circuit may be substantially influenced by
the frequency of the current flow, these devices have been called
“frequency dependent”
 In biologic settings, the reactive component facilitates the flow of
alternating current, more for higher than for lower frequencies.
 Thus, a tissue through which two alternating currents of differing
frequencies are flowing will impede the lower-frequency current more
than the higher-frequency current.
 The reactive component of the circuit may change, for example, as the
position of a file changes in a canal. When this occurs, the impedances
offered by the circuit to currents of differing frequencies will change
relative to each other.
 This is the principle on which the operation of the “third-generation”
apex locators is based

 Endex (Osada Electric Co., Los Angeles, Calif. And Japan) –In Europe
and Asia, this device is available as the APIT
 The Neosono Ultima Ez Apex Locator (Satelec Inc; Mount Laurel, N.J.)
 The Mark V Plus (Moyco/Union Broach, Miller Dental, Bethpage, N.Y.)
 The JUSTWO or JUSTY II (Toesco Toei Engineering Co./Medidenta,
Woodside, N.Y. and Japan)
 The APEX FINDER A.F.A. (“All Fluids Allowed”—Model 7005,
Sybron Endo/Analytic; Orange, Calif.)
 The ROOT ZX (J.Morita Mfg. Co.; Irvine, Calif. And Japan),
 1990 – Yamashita – reported a device that works by comparing the
impedance difference of two alternating currents at 1 & 5 kHz
frequencies – Marketed as Endex (Osada, Japan)
 Advantage: works well in presence of pus or electrolytes
 Disadvantage: calibration needed to be done each time

 AFA (all fluids allowed) Apex Finder Model 7005 (Analytic

Endodontics, California) – another frequency dependant EAL – uses five
frequencies (0.5, 1, 2, 4, 8 kHz)

 1991 – Kobayashi et al – “ratio method” – basic working mechanism of

Root ZX (J Morita, California) – this device measures the impedances of
0.4 kHz and 8 kHz at the same time, calculates the ratio of the
impedances, and expresses this ratio in terms of the file position in the
canal.
 The Root ZX is mainly based on detecting the change in electrical
capacitance that occurs near the apical constriction
 Advantage: this ratio not affected by electrical condition in the canal,
calibration not necessary each time, reported to be quite accurate in
various canal conditions

Fourth-Generation Apex Locators.

The Bingo 1020 (Forum Engg. Tech., Israel) – uses two separate frequencies
400Hz and 8 kHz, but only a single frequency at a time
 This eliminates the need for filters that separate the different frequencies
of the complex signal
 Position of the file tip is calculated based on the measurements of the
root mean square value of the signal.
 Manufacturer claims that a combination of these two techniques
increases the accuracy
ProPex (Dentsply maillefer) – works similar to Bingo, but uses a multi-
frequency approach – locate apical foramen with great precision in any
canal condition – ergonomic design

Apex locators with other functions –

 EALs with additional functions developed in late 1990s
 Solfy ZX (J Morita) = ultrasonic handpiece + Root ZX
 Tri Auto ZX (J Morita) = Root ZX + cordless rechargeable electric hand
piece that uses a NiTi rotary file with 260 to 280 rpm
 When file reaches the required location, device allows the file to rotate
back out of the canal – prevent overinstrumentation – also prevents
fracture of the NiTi rotary file
 Disadvantage: number of rpm reduces with increasing pressure due to
limitation of the rechargeable battery
 Recently, the Dentaport ZX (J Morita) introduced
 Two modules – Root ZX module & Tri Auto ZX module
 Advantage: auto apical slow down function – when the file reaches the
apical constricture, the rpm slows down allowing for careful sculpture of
the apical portion
 Further research is needed
 Elements Diagnostic Unit (Sybron Endo, California) = apex locator +
electric pulp tester
General accuracy of frequency dependant EALs
 Much higher than that of traditional type EALs
 Most of the EAL measurements compared with the actual tooth
length

 Kaufman et al 2002 – compared Bingo 1020 with Root ZX & found that
Bingo 1020 consistently more accurate than Root ZX
 The ± 0.5 mm clinical tolerance is considered to be the strictest
acceptable range. Therefore, measurements attained in this tolerance
were considered to be highly accurate.
 Some authors prefer ± 1 mm range
(Goldberg et al 2002, Kielbassa et al 2003)
 Shabahang et al (1996) reported that an error tolerance of ± 1 mm can be
deemed clinically acceptable, because root canals frequently lack a well-
delineated apical constriction
Accuracy of frequency dependant EALs in different electrolytes
 Frank & Torabinajad (1993) – found that Endex located the apical
constriction accurately within ± 0.5 mm clinical tolerance in 89.64 %
moist canals.
 Meares & Steiman (2002) – Root ZX not adversely affected by the
presence of NaOCl
 Jenkins et al (2001) – showed Root ZX reliably measured the canal
length to within 0.31 mm regardless of the irrigants; however largest
deviation – with NaOCl
 Pilot & Pitts (1997) – highest error with NaOCl
 Kim et al (2000) reported – short measurements in a high
electroconductive solution such as NaOCl, longer measurements in the
lower electroconductive solution

 Measurements can change as a result of different measuring methods

such as coronal (cusp tip or flattened occlusal table) or apical reference
point (major diameter or constriction point)
 Most studies reported pulpal vitality does not affect EAL accuracy.
However, there have been several disagreement also
 No significant difference in accuracy of EALs regarding the file size
used (Nguyen et al 1996, Lee et al 2002)
 Use of EALs in apical resorption is under question because of
possible destruction of apical constricture & loss of surrounding PDL
tissue
 Accuracy in primary teeth - The location of actual apical foramen in
primary teeth, which are in the process of physiologic resorption - a great
challenge
 Apical aperture is exposed to continuous or irregular resorption.
 Necessity to minimize the periapical damage to protect the succedaneous
tooth bud
 Katz et al (1996), Kielbass et al (2003) – reported Root ZX had a
sufficient accuracy in primary teeth
 Detection of root perforation – use of EAL for early detection of a root
perforation appears to be very effective (Kaufman et al 1997)
 Effect of different metal types – no statistical difference in accuracy of
EALs by using different types of metal viz., NiTi or st. steel instruments
Clinical suggestions
 As EALS only provide the electronic impedance and not the canal shape.
To obtain anatomic information of the root and the canals, a radiograph
still is mandatory in an endodontic procedure
 Working length is changing continuously – widening of the apical
constricture, straightening of curved canals
 Common problems and problem solving
 Unstable signal with rapid wandering signs – remove metallic restoration
 Sharp drop of signal at apical foramen – dry canal – gentle irrigation of
the canal
 Apex sign from the beginning – too much electrolyte in the canal –
irrigate gently with NaOCl & NaCl

Advantages of EALs
 Devices are mobile, light weight and easy to use
 Much less time required
 Additional radiation to the patient can be reduced (particularly useful in
cases of pregnancy)
 80 - 97 % accuracy observed

Disadvantages of EALs
 A learning curve required
 Accuracy limited to mature root apices
 Extensive periapical lesion can give faulty readings
 Weak batteries can affect accuracy
 Can interfere with functioning of artificial cardiac pacemakers – cautious
use in such patients
 Apex locators vs. Radiographs

 It is a mistake to think that apex locators will eliminate radiographs

during endodontic treatment
 Excellent pre-operative films must always be taken prior to any active
treatment on the tooth
 Apex locators cannot help the dentist determine canal width, canal
curvature, or number of canals
 These must be determined by radiographs
 Fouad et al – apex locators were not meant to replace radiographs, but to
add to the information obtained by radiographs
 Summary & Conclusion

 The CDJ or minor diameter is a practical and anatomic termination point

for the preparation and obturation of the root canal – and this cannot be
determined radiographically
 Modern apex locators can determine this position with accuracies greater
than 90% but with some limitations
 No individual method is truly satisfactory in determining endodontic
working length
 Therefore, combination of methods should be used to assess the accurate
working length determination
 Knowledge of apical anatomy, prudent use of radiographs and correct use
of electronic apex locator will assist practitioners to achieve predictable
results
 References
Textbooks
 Ingle JI, Bakland LK: Endodontics, 5th ed.
 Grossman LI & others: Endodontic Practice, 11th ed.
 Weine FS: Endodontic Therapy, 6th ed.
 Walton RE, Torabinajed M: Principles and Practice of Endodontics
 Chandra S & Chandra S: Textbook of Endodontics
 Pitt Ford TR: Harty’s Endodontics in Clinical Practice, 4th ed.
Journal articles –
1. Gordon MPJ, Chandler NP: Review Electronic Apex Locators, IEJ, 2004,
37, 425-437.
2. Serota KS & others: the new era of foramenal location, FACE-2, 2005,
28-32.
3. Moshonov J, Slutzky-Goldberg I: Apex Locators: Update and Prospects
for the Future, Int Jr of Computerized Dentistry, 2004, 7, 359-370
4. Kim E, Lee SJ: Electronic apex locator, DCNA, 2004, 48, 35- 54
5. Kobayashi C: Electronic canal length measurement, triple O,1995, 79,
226-31
6. Stock C: Endodontics- position of the apical seal, BDJ, 1994, 176, 329
7. Kuttler Y: Microscopic investigation of root apices, JADA, 1955, 50, 544
8. Dummer et al: the position and topography of the apical canal
constriction and apical foramen, IEJ, 1984, 17, 192-198
9. Fouad AF: the use of electronic apex locators in endodontic therapy, IEJ,
1993, 26, 13-14.
10.Shabahang et al: An in vivo evaluation of Root ZX electronic apex
locator, JOE, 22, 11, 616-18