ACCURATE WORKING LENGTH DETERMINATION

Solaiman Al-Hadlaq B.D.S., M.S., Ph.D

Where to end your root canal preparation?

The proper point to which root canals should be filled is the junction of the dentin and the cementum and that the pulp should be severed at the point of its union with the periodontal membrane
Groove C., JADA 1930

Methods of Working Length Determination

Predetermined normal tooth length Radiographs Tactile sense Paper points Patient response Electronic Apex Locators

Anatomy of the Root Apex

2 3 1

1. 2. 3.

Tooth apex (radiographic apex) Apical foramen (major foramen) Apical constriction (minor foramen)

Anatomy of the Root Apex

1 2 3

Johnson WT, Color atlas of Endodontics, 2002

Anatomy of the Root Apex

1

1. 2. 3.

Tooth apex (radiographic apex) Apical foramen (major foramen) Apical constriction (minor foramen)

2 3

Anatomy of the Root Apex

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.
Kuttler, JADA, 1955; Green, OOO, 1960; Pineda and Kuttler, Oral Surg, 1972; Burch and Hulen, Oral Surg, 1972; Dummer et al., Int Endo J, 1984 2 3 1

1. 2. 3.

Tooth apex (radiographic apex) Apical foramen (major foramen) Apical constriction (minor foramen)

Anatomy of the Root Apex

Distance between 2 and 3:
 0.5 mm in 18-25 y old, and 0.7 in 55+ y old.
Kuttler, JADA, 1955, 2 3 1

Distance between 1 and 3:

 0.89 mm with a range of 0.1 to 2.7 mm.
Dummer et al., Int Endo J, 1984
1. 2. 3. Tooth apex (radiographic apex) Apical foramen (major foramen) Apical constriction (minor foramen)

Anatomy of the Root Apex

Johnson WT, Color atlas of Endodontics, 2002

Anatomy of the Root Apex

Johnson WT, Color atlas of Endodontics, 2002

Anatomy of the Root Apex

Johnson WT, Color atlas of Endodontics, 2002

46 %

30 %

19 %

5%

Dummer et al., Int Endo J, 1984

Bergenholtz G et al., Textboook of Endodontology, 2002

Bergenholtz G et al., Textboook of Endodontology, 2002

 When radiographic working length in vitro was set to be 0.5 2.0 mm short of the apex:
 25% of the time the file was beyond the apical foramen.  51% of premolars and 22 % of molars were beyond the apical foramen.  66% of files were longer than a point 0.5 mm shorter than the apical foramen.
ElAyouti A et al., J Endodon, 2001

Walton and Torabinejad., Principles and practice of Endodontics, 1996

Electronic Apex Locators

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

Electronic Apex Locators

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

Electronic Apex Locators

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

Electronic Apex Locators

First generation
Resistance type 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. Unreliable, electrolytes, exudate, hemorrhage, vital pulp tissue, and excessive moisture caused inaccurate results.

Electronic Apex Locators

Second generation
Single frequency impedance. Highest impedance at the apical constriction. Need to be calibrated before each use. Sono-Explorer, Endocator (sheath over probe). Incorrect readings with electrolytes in the canal.

Electronic Apex Locators

Third generation Multiple frequencies to measure impedance. Calculate difference or ratio of impedance.

Electronic Apex Locators

Third generation Endex (Osada Electric, Tokyo, Japan) measures the difference between two impdances. It works in the presence of pus and electrolytes. Needs to be calibrated for each canal.

Electronic Apex Locators

Third generation Endex has an average accuracy of 81% to within + 0.5 mm of the apical foramen.
Investigator Fouad et al. (1993) Mayeda et al. (1993) Frank & Torabinejad (1993) Felippe 8< Scares (1994) Arora & Gulabivala (1995) Pratten & McDonald (1996) Lauper etal. (1996) Ounsi & Haddad (1998) Weiger et al. (1999) De Moor et al. (1999) Martinez-Lozano et al. (2001) Accuracy (%) 73 (0.5 mm) 66 (0.75 mm) 90 (0.5 mm) 96.5 (0.5 mm) 72 (0.5 mm) 82 (0.5 mm) 93 (0.5 mm) 85 (0.5 mm) 59 (0.5 mm) 100 (0.5 mm) 68 (0.5 mm) Test condition In vitro - NaOCI In vivo In vivo In vitro In vivo In vitro In vivo In vitro In vitro - NaOCI In vitro In vitro Compared with Tooth length Tooth length RM Tooth length Tooth length RM and tooth length Tooth length Tooth length Tooth length Tooth length Tooth length

Accuracy studies for the Endex/ Apit apex locator (Gordon and Chandler, 2004)

Electronic Apex Locators

Third generation Root ZX (J. Morita, Tokyo, Japan) measures the ratio of two impedance frequencies. Self calibrating. Was not affected by electrolytes in the canal.

Root ZX has an average accuracy of 89 % to within + 0.5 mm of the apical foramen.

Investigator Variable tested Accuracy (%) Compared with Sample (n)

Clinical accuracy permanent teeth in vitro Czerw et al. (1995) Accuracy in vitro White et al. (1996) Accuracy in vitro Ounsi & Naaman (1999) Accuracy in vitro Accuracy in the presence of irrigants Shabahang et al. (1996) Accuracy in vivo McGinty et al. (1996) Irrigants and accuracy in vitro Weiger et al, (1999) Jenkins era/. (2001) Meares & Steiman (2002) Irrigants and accuracy in vitro - NaOCI Various irrigants and accuracy in vitro Accuracy with NaOCI in vitro

100 (0.5 mm) 84 (0.5 mm) 85 (0.5 mm)

Tooth length Tooth length Tooth length

30 51 39

96 (0.5 mm) No difference between irrigants 85 (0.5 mm) No difference 83 (0.5 mm) No difference

Extracted tooth length Tooth length Tooth length Tooth length Tooth length

26 16 41 30 40

Clinical accuracy permanent teeth in vivo Vajrabhaya & Accuracy in vivo Tepmongkol (1997) Pagavino et al. (1998) Accuracy in vivo - SEM Dunlap et al. (1998) McDonald et a/. (1999) Welk et al. (2003) Accuracy vital versus necrotic in vivo Accuracy in vivo Accuracy in vivo

100 (0.5 mm) 83 (0.5 mm) 82 (0.5 mm) 95 (0.5 mm) 91 (0.5 mm) Minor diameter

Extracted tooth length Extracted tooth 100 (1.0 mm) Extracted tooth Extracted tooth Extracted tooth length length length length

20 29 34 20 32

Clinical accuracy in primary teeth Katz et al. (1996) Accuracy in primary teeth - in vitro Mente et al. (2002) Accuracy in resorbed primary teeth In vitro Kielbassa et al. (2003) Accuracy in primary teeth - in vivo

100 (0.5 mm) 98 (1.0 mm) 64 (1.0 mm)

Extracted tooth length Tooth length Extracted tooth length

20 24 71

The properties of the Root ZX (Gordon and Chandler, 2004)

Electronic Apex Locators

Other third generation apex locators Apex Finder AFA (EIE Analytic Endodontics, CA)
 Five frequencies  86 % accuracy at 1 + 0.5 mm from radiographic apex.
Pommer et al., JOE, 2002

Bingo 1020 (Forum Engineering Technologies, Lishon Lezion, Israel) also marketed as Ray-Pex 4 (Dentsplay).
 Two separate frequencies  No difference between Root ZX or Bingo under different irrigants. Kaufman et al., Int Endo J, 2002

Electronic Apex Locators

Other third generation apex locators Justy II (Yoshida Co., Tokyo, Japan)
 82 % accuracy in determining the area between minor and major foramen. Hoer and Attin, Int Endo J, 2004.

Endy 5000 (Loser, Leverkusen, Germany)

 81 % accuracy in determining the area between minor and major foramen. Hoer and Attin, Int Endo J, 2004.

Neosono Ultima EZ (Satelec Inc., NJ)

 100 % accuracy within 0.5 mm range. De moor et al,
Endodon Dent Traumatol, 1999.

Mark V plus (Moyco/Union Broach, Bethpage, NY)

Electronic Apex Locators

Apex locators with other functions Tri Auto ZX (J. Morita Corp) an apex locator and a rechargeable electric handpiece for NiTi rotary files. 95 % accuracy to within 0.5 mm of the constriction. Gimberg et al., Int Endo J,
2002

Electronic Apex Locators

Apex locators with other functions Dentaport ZX (J. Morita Corp) is Root ZX with attached endodontic hand piece for rotary NiTi files.

Electronic Apex Locators

Apex locators with other functions Element Diagnostic Unit (SybronEndo, CA) and Apex Locator and EPT.

 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.

Cohen and Burns., Pathways of the Pulp, 2002

 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).

Acceptance of Electronic Apex Locators

Investigator Whitten et al. (1996) Saunders et al. (1999) Yoshikawa et al. (2001) Chandler & Koshy (2002) Hommez et al. (2003) Country USA Scotland Japan New Zealand Belgium Use GDPs GDPs GDPs GDPs Specialists GDPs % 10 7.7 90 27.5 60 16

Electronic apex locator use (Gordon and Chandler, 2004)

 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.

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.

Accurate Working Length Determination

A recent preoperative diagnostic quality radiograph is a must. Do not rely on a single method for accurate working length determination. Preflare the canal to increase your tactile sensation. Use an Electronic Apex Locator to determine you working length. Confirm you working length with a radiograph.

Accurate Working Length Determination

The key to accurate working length determination is clear understanding of apex anatomy, knowledge of limitations of current techniques, and corroboration of information gained by different methods for working length determination.

Thank you