CAREER POST GRADUATE INSTITUTE OF

DENTAL
SCIENCES & HOSPITAL

Comparative evaluation of different techniques of

working length determination with CBCT in - an in
vitro study

Presented by:Anubha Saxena

PG 1st year
Dept. of
conservative
dentistr&
Endodontics

INTRODUCTION
One of the main concerns in root canal treatment is to
determine how far working files should be advanced
within the root canal, and at what point the
preparation and obturation should be terminated
Over-instrumentation can cause tissue destruction,
persisting inflammatory responses, and foreign body
reactions
Under-preparation or insufficient cleaning of the canal
will entail the risk of leaving tissue remanents within
the
apical region; as these tissue may be diseased,
treatment may fail]

The literature suggests two valid positions for

apical
stop preparation: At the cemento-dentinal junction
(CDJ), or at the minor apical foramen
Locating the apical constriction and cementdentinal
junction clinically is challenging because of their
variable positions and topography
Traditional methods for estimating working length
are radiography, anatomical averages and
knowledge of anatomy, tactile sensation, and
moisture
on a paper point

In recent years to overcome limitations offered

by
traditional methods, new techniques have been
introduced,
which
include
digital
radiography,apex
locators
and
Cone
Beam
Computed
Tomography.
The
the

electronic method

eliminates

many

of

problems associated with radiographic

methods.
It is more accurate, easy and fast, with no
requirements of X-ray exposures

It requires special devices, and the accuracy is

influenced by condition of the canal. The presence of
tissue and conductive irrigants in the canal can
change the electrical characteristics and lead to
measurement error.
The most recent generation of dual frequency
apexlocators have attempted to minimize this problem.
The main disadvantages of electronic apex locators
are that it cannot be used in patients with cardiac
pacemakers, perforations, root fractures , immature
apex & root resorption, and their accuracy are also
questionable in cases of hemorrhage and swelling

Digital radiology that generates images by

means of
an X-ray sensor instead of conventional film
had
many
advantages
over
conventional
radiographs.
they are :
Speed of image acquisition
reduced patient irradiation,
possibility of editing the image
A quality of detail similar to that afforded by
conventional radiology.

Recently Cone Beam Computed Tomography was

introduced in endodontics as a noninvasive
method of
diagnosing disease and to evaluate tooth
morphology.
It is more sensitive than periapical radiographs in
detecting pre- and post-treatment periapical
lesions,
root canal anatomy , vertical root fractures , root
perforations and post-treatment periapical
lesions.
A major advantage of Cone beam computed
tomography is the three-dimensional imaging.

REVIEW OF LITERATURE
F.Somma et al. has compared in vivo three different
electronic root canal length measurement devices:
Dentaport ZX, Raypex 5 and Propex . He has selected
thirty single rooted permanent teeth from 10 adult
patients and divided into three groups of 10 teeth. The
working length in Group was determined using
Dentaport ZX apex locator. A K-file with the largest
diameter that could reach the last green bar on the
screen was stabilized in the canal using a dual-curable
flow resin composite. The same procedure was used for
the Raypex 5 ( the file reached the last yellow bar) and
Propex (0.0 orange bar) apex locator.The teeth were
then extracted and cleared. The distance between the tip
of the file and the major foramen was then calculated for
each tooth using digital photography according to
Axiovision AC software .Under the in vivo conditions of
this study, the three electronic root canal length
measurement devices were not significantly different in
terms of locating the major foramen.

J.P.Vieyra et al. evaluated the accuracy of the

Root ZX ,Elements- Diagnostic, Precision AL and
Raypex 5 electronic apex locators when
compared to radiographs for locating the apical
constriction.The apical constriction of 693
canals in 245 maxillary and mandibular teeth
was located in vivo . After extraction the actual
location of apical constriction was determined
visually and with magnification. Measuring the
location of the apical constriction using the
four apex locators was most accurate than
radiographs and would reduce the risk of
instrumenting and filling beyond the apical
foramen.

V.Miletic et al. compaired the reproducibility of

three electronic apex locators: Dentaport ZX,
RomiApex A-15 and Raypex 5 , under clinical
conditions. Fourtry-eight root canals of incisors,
canines
and
premolars
with
or
without
radiographically
confirmed
periapical
lesions
required root canal treatment in 42 patients. In each
root canal, all three EALs were used to determine
the working length that was defined as the zero
reading and indicated by APEX, 0.0 or Red
square marking on the EAL display. The clinical
reproducibility of dentaport ZX ,RomiApex A-15 and
Raypex 5 was confirmed with the majority of
readings within the 1-0 mm range. However, the
small number of identical zero readings suggests
that EALs are not reliable as the sole means of WL
determination under clinical conditions.

P.Oliver et al. compaired the appearance of healthy

periapical tissues on cone-beam computed tomography
with periapical radiography and to measure the
periodontal ligament space on CBCT for teeth with
healthy and necrotic pulps. The direct application of
traditional interpretation of periapical radiography to
Cone Beam Computed Tomography interpretation may
be flawed because the normal 3-dimensional anatomy
of the periodontal ligament space appears to entail
greater variation than previously thought. The findings
of this study indicate that with Cone beam computed
tomography, the majority of vital teeth show some
degree of periodontal ligament widening. Additional
research is required to develop our understanding of
the appearance of healthy periapex and the
manifestation of the apical periodontitis on Cone beam
computed tomography before use in outcome studies.

T.Ayusun kara et al. has evaluated the effect of working

length determination methods, electronic apex locator
and digital radiography, on postoperative pain. Two
hundred twenty patients with asymptomatic single
rooted vital teeth were randomly assigned to 2 groups
according to the method used for working length
determination.After
working
lengh
determination,
chemomechanical prepration was performed in a crwon
down technique with ProTaper instruments. A master
cone radiograph was taken. Canals were obturated with
gutta percha and sealers by using a lateral compaction
technique. Postoperative pain was assessed after
4,6,12,24 and 48 hours by using a 4-point pain intensity
scale. There was no difference in post operative pain
between working length measurement methods by using
an electronic apex locato or digital radiography. The
reduced exposure to radiation by using apex locator may
be a factor that influences a dentists dec ision to choose
the electronic apex locator over radiography.

AIM
To evaluate the working length by three
different techniques that is conventional tactile
technique, Radio visuo graphy and Apex locator
and comparition of working length is done by
Cone beam computed tomography technique.

MATERIAL AND METHOD

40 patients of both the sexes in age group of 20
to 60 years will be included

Case history and clinical examination of the

patient

Thorough oral prophylaxis will be done

Local anaesthesia will be administered

Rubber dam application will be done

In those cases where one or more marginal ridges

are involved provisional restoration will be
provided

The access cavity will be prepared

Stable reference point will be created for each

canal

initial patency of the root canal will be done with

ISO size 15 K-file

Irrigation with 2.5% sodium hypochlorite

Working length will be determined by three

different techniques

Tactile
technique

RVG
technique

Apex locator

Verification of working length will be done by

Cone Beam Computed Tomography

Data will be analyzed statistically

Result

Discussion

Conclusion

If deemed necessary changes will be made in

the study.

PILOT STUDY
Preopertaive
image

Access opening and

Rubber dam application

TACTILE TECHNIQUE
Working Length
of Mesiobuccal canal
36:-20mm

TACTILE TECHNIQUE
Working length
of mesio
lingual canal
36 :- 19mm

APEX LOCATOR TECHNIQUE

Working length
of mesio
lingual canal
36 :- 20mm

APEX LOCATOR TECHNIQUE

Working length
of mesio
lingual canal 36
:-19.8mm

RADIO VISUAL GRAPHY TECHNIQUE

Working length of mesio buccal canal 36:20.9mm

RADIO VISUAL GRAPHY TECHNIQUE

Working length of mesio lingual canal 36:19.8mm

Cone Beam Computed Tomography

technique

Working length of mesio buccal canal 36:22.08mm

Cone Beam Computed Tomography

technique

Working length of mesio buccal canal 36:19.97mm

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THANK YOU