GOODMORNING

GOOD MORNING
DETERMINATION OF WORKING
LENGTH

Presented by
Dr. Ranu Choudhury
MDS 2nd year
Dept. of Conservative Dentistry & Endodontics
Content :
• Introduction
• Anatomical consideration
• Methodological consideration
• Methods of working length determination
• Radiological method
• Methods other than radiological method
• Electronic apex locator
• conclusion
Introduction :
• The term “Working Length” is defined as “the distance from
a coronal reference point to that point at which canal
preparation and obturation should terminate”.
– Glossary of endodontic terms. 7th edition.
The significance of correct working length:
• It determines how far into the canal the instruments are
placed and worked, i.e. how deeply into the tooth the tissues,
debris, and other unwanted items are removed from the
canal.
• It will 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 following the appointment.
• If determined correctly it will play an important role in the
success of the treatment, and conversely, if it is incorrect
then it may doom the treatment to failure.
• An erroneously short
working length leaves
unclean and unfilled canal
space in the apical region.
• An erroneously long
working length will lead to
over-instrumentation &
over extended obturation,
causing significant post
operative discomfort.
Anatomical consideration:
• Anatomical apex: It is the • Radiographical apex: It is
tip or end of the root the tip or end of the root
determined determined
morphologically. radiographycally.
• But due to the root morphology & radiographic distortion the
location of the radiographic apex to vary from the anatomical
apex.
Apical foramen:
• It is the main apical opening of the root canal.
• It is often eccentrically located away from the anatomical or
the radiographic apex.

•Kuttler’s investigation
showed that this
deviation occurred in 68
to 80% of cases.
[Kuttler Y. Microscopic
investigation of the root apexs. J
Am Dent Assoc. 1955; 50: 544 ]
 According to the studies of 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 layer
of cementum. It is referred to as
the minor diameter of the root
canal. It is also called as the apical
constriction.
• The diameter of the site where the
canal exits from the tooth is the
major diameter.
• It was found that major diameter is
approximately twice as wide as the
minor diameter
• The average distances between the minor and the major diameters were
0.524mm in teeth examined in an 18 to 25 year old group and 0.659mm in
55 year old and older age group.

•From the crown, the canal tapers

down to the minor diameter and
then widens again as it approaches
the site of exiting from the root
(major diameter).
The space between minor diameter
and major diameter is hyperbolic or
funnel shaped; Kuttler referred to it
as the shape of morning-glory
flower.
• Cementodentinal junction:
• It is the region where the dentin & the cementum are united.
• It is a histological landmark that cannot be located clinically or
radiographically.
• The location of CDJ ranges from 0.5 to 3mm short of the
anatomical apex.
• Langeland reported that the CDJ does not always coincide
with apical constriction.
DUMMER CLASSIFIED APICAL CONSTRICTION
INTO 4 DISTINCT TYPES (1984)
The apical termination of root canal preparation:

• “the dentin-cementum
junction has been
recommended as an ideal
apical termination for root
canal preparation”.
– John I. Ingle
• It is the narrowest portal of
entry of the pulpal vasculature
from the periapical tissues and
would be the smallest wound
following pulpal removal
• It forms a natural apical
matrix against which root
canal filling can be done.
Methodological consideration:
• Proper access cavity
preparation has to be done
to provide a straight line
pathway to the canal orifice.

• Modifications in access
preparation is required to
permit the instrument to
penetrate unimpeded into
the apical constriction
• In step back technique, working length determination is done
first & then canal is prepared.
• Crown-down preparation technique includes WL
determination after initial shaping.
• A definite, repeatable plane of reference to an anatomical
landmark on the tooth – is necessary.
Reference point:

• It is the site on occlusal

surface or incisal edge from
which measurements are
made.
• This point is used through
the canal preparation and
obturation.
• This point should be in close
proximity to the straight-
line path of the instrument.
• Any weakened enamel wall
or diagonal line of fracture
should not be used as
reference point.
• Weakened cusps or
fractured incisal edge
should be reduced to a
flattened surface,
supported by dentin.
Methods of working length determination:

• The most common method is the radiographic method.

• The other methods includes:
– Digital tactile sense method
– Paper point method
– Use of electronic apex locator
Determination of Working Length by
Radiographic Method
The following items are essential to perform radiographic
working length determination:

• Good undistorted preoperative radiograph showing the total length

& all roots of the involved tooth.
• Adequate coronal access to all canals
• An endodontic millimeter ruler
• Correct knowledge of the average length of all the teeth.
• A definite, repeatable plane of reference to an anatomical landmark
on the tooth
• A K-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 and may
cause error. Moreover, tips of fine instruments (size 08 & 10) are
often difficult to see in a radiograph and also the NiTi instruments.
Radiographic method:

• Ingle’s method
• Kuttler’s method
• Weine’s modification
• Mathemetical method
Ingle’s method of working length determination:
• The canal length is estimated
preliminary from a preoperative
radiograph.
• About 1mm “safety allowance”
for possible image distortion is
deducted.
• The endodontic ruler is set to this
tentative WL & the stop on the
instrument is adjusted at this
level.
• The instrument is placed in the
canal until the stop is at the plane
of reference unless pain is felt, in
that case the instrument is left at
this level & the rubber stop
readjusted.
• Another radiograph is taken at
this point and the difference
between the end of the
instrument and the end of the
root is determined.
• 1mm safety allowance should be
given to conform the apical
termination of the root canal
preparation at the apical
constriction.
Kuttler’s method:
• According to kuttler, canal preparation should terminate at apical
constriction, i.e. minor diameter.
• In young patient, average distance between nimor & major diameter is
0.524mm where as in older patients it is 0.66mm.
Technique:-
 Locate minor & major diameter on preoperative radiograph.
 Estimate length of the roots from preoperative 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, when
canal is wide use 30 or 35 size instrument.
 Insert selected file in canal up to the estimated canal length & radiograph
is taken.
 If the file reaches major diameter, subtract 0.5 mm from it for patients
younger than 35years and 0.67mm for older patient.
Weine’s subtraction rule:

• If radiograph shows absence of any resorption, i.e. in bone or root apex,

shorten the length by 0.5mm.
• If definite periapical radiolucency is present with radiographic indication
of apical resorption, the apical preparation must end an additional 0.5mm
from the calculated working length.
• If radiographically visible apical root resoption is extensive, it might be
necessary to shorten this length by as much as 2mm or more to allow for
the dentin matrix.

0.5mm (0.5 +
+0.5)
 Mathematical method of working length
determination:

• The canal length is estimated preliminary from a preoperative radiograph

• An instrument is inserted into the canal up to that length, & stopper is fixed to
the reference point & radiograph taken.
• The formula to calculate actual length of the tooth is as follows:-
Actual length of the tooth = Apparent length of the tooth in radiograph
Actual length of the instrument Apparent length of the instrument in
radiograph
Hence,
Actual length of the tooth =
Actual length of the instrument x Apparent length of the tooth in radiograph
Apparent length of instrument in radiograph

The methods requiring formula to calculate working length are now abandoned
because only a small percentage of successful results found. - Ingle
Some additional considerations about radiographic
technique:

• When two canals located in the bucco-lingual plane appears

to be superimposed:
– Take individual radiograph of each canal with its length-of-tooth
instrument in place. or
– radiograph can be taken from a mesial horizontal angle with
instruments present in each canal, this results in lingual canal to
appear more mesial one in the image (according to Clark’ rule / SLOB
rule). Or
– Insert two different type of instruments like K-file in one canal and H-
file in the other and radiograph is taken at different horizontal
angulations. This cause identification of the canals separately.
What type of radiographic technique is preferred?

• Several studies are there , but the results are confusing !

• According to the review article by Osama S Alothmani et al.:
– E-speed film was found to be as good as D-speed film for
radiographic WL determination when a size 15 file was
used
– Although the accuracy of WL determination with D,E and
F-speed films was similar, D-speed film received a higher
subjective rating than other types regarding the clarity of a
size 08 & 10 file.
[Radiographic assessment of endodontic working length: Osama S
Alothmani, LT Friedlander, N P Chandler; Soudi Endodontic Journal:
2013; vol.3, p: 57-64]
• It is also unclear if digital radiography is better than
conventional films regarding accuracy of WL determination.

• Inferior as well as superior results were reported for phosphor

plate system.

• Sensor based RVG [direct sensor] performed similar to films

regarding accuracy in some studies, also some studies showed
superior results.
[Ingle]
• Osama S Alothmani et al. concluded in their review article
that digital radiography was found to be comparable to
conventional radiography for Wl determination especially
when larger files were used.
• Image manipulation and enhancement is mandatory for
optimum interpretation.
• Although digital images are instantly available, their
manipulation takes time and requires experience.
• As lower radiation dose is required digital radiography offers
less radiation exposure to the patient
Determination of Working Length by
Non radiographic Method
 Digital tactile sense method
• An experienced clinician can
literally feel the apical
constriction by tactile sense
when an instrument is
inserted up to the root
apex.
• Although it may appear to
be very simple, its accuracy
needs sufficient experience.
• Confirmation may be done
either by the radiographic
or by electronic method.
• Pre-flaring of the canal is
necessary for this method. If
the canals are pre-flared WL
can be detected accurately in
75% of cases.
• This method is ineffective in
– root canal with an immature
apex
– when the canal is constricted
through its entire length
– if the canal has excessive
curvature.
• Therefore, this method should
be considered as a
supplementary one
Paper point method:
• In a root canal with an immature (wide open) apex
this technique can be used.
• The blunt end of the paper point is gently pass into
the canal toward the apex after profound anesthesia
has been achieved.
• The canal should be free of bleeding or suppuration.

• The moisture or blood can be seen on the portion of the

paper point that passes beyond the apex, and this may be an
estimation of the junction between the root apex and bone.
• This method is also a supplementary method.
Electronic Apex Locator:
Electronic Apex Locator:
• An apex locator is an electronic device used in endodontics to determine
the position of the apical foramen and thus determine the length of the
root canal space.
• The electrical method for root length determination was first investigated
by Custer (1918).
• The idea was revisited by Suzuki in 1942. He found that electrical
resistance between the periodontium and oral mucous membrane in dogs
was a constant value.
• Sunada took this principle and constructed a simple device that used
direct current to measure the canal length. It worked on the principle that
electrical resistance between the oral mucous membrane and the
periodontium in human was constant at 6.5kΩ, regardless of the age of
the patients or the shape and type of teeth.
– Sunada I. new method for measuring the length of the root canal. J
Dent Res 1962; v41: 375-87
How Apex Locator works?
• Apex locators function by using human body to complete an electrical
circuit.
• They measure the difference in electrical resistance (impedance) between
the lip and the file inside the tooth.
• One side of the apex locator circuit is connected to the oral mucosa
through a lip clip and in other side to a file that is placed in the root canal.

Typical circuit for electronic

determination of working length
• The resistance between the lip and the PDL is a known value, thus, as the
file tip advances toward the PDL, the ELA detects the changing resistance
values and indicates the approach to the apex on its screen.

• When the file tip touch the PDL, it is indicated visually on the screen.
• Since the file contacting the PDL it is just past the apical constriction. This
information then is used in length determination.
Terminologies
Direct current (DC)- fixed amount of current per unit of time

Alternating current (AC) – amount of current that alters with

time

A sine wave as an
alternating current

Frequency (f) = number of cycles that a sine wave completes

in 1 sec (more the cycles in 1sec ---higher the frequency)
• Resistance: opposition to the direct current
• Impedance : total amount of opposition to an alternating
current. Impedance has two components:
• Resistance and capacitance
• Capacitor – a structure of 2 conductive material with an
insulator between them form an electrical device called as
capacitor

c
A simple capacitor
connected to a
battery →
– Capacitance: the amount of charge that a capacitor can
store
• Depends upon :
– plate area
– separation
– Dielectric constant
– Capacitor blocks DC as a result of insulator and allows
AC to pass with some amount of opposition that
depends on its capacitance and frequency of AC.
Electrical Features Of The Tooth Structure
• When the file approaches
the canal terminus, the
resistance between the
end of the instrument and
the apical portion of the
canal decreases, because
the effective length of the
resistive material inside
the canal decreases.
Classification on Apex Locator

• First generation: Resistance Apex Locator

• Second generation: Impedance Apex Locator

• Third generation: Frequency dependent Apex Locator

• 4th 5th & 6th generation are also available.

• First generation Apex locator:
– Also known as resistance apex locator
– Measures opposition of the flow of direct current or
resistance.
– Dry canal was mandatory; electrolyte, exudates,
hemorrhage, vital pulp tissue can give inaccurate result
– The disadvantage : pain often felt due to high electric
currents
– Today, most 1st generation devices are out of the market.
– Examples are: Root canal Meter, Endodontic meter
 Second generation Apex Locator
• Also known as impedance
based apex locator
• Measure opposition to the
flow of alternating current
or impedance.
• These are of single
frequency impedance type

• The presence of tissue and

electroconductive irrigants
in the canal changes the
electrical characteristics and
leads to inaccuracy, usually
shorter reading.
• To overcome the problem of
a wet environment,
insulated probes are used
instead of K-file
• They had to be calibrated
before use for each canal.
And the insulated probe
was quite thick, could not
be used in narrow canals.
Sono Explorer
• Examples are: Sono-
Explorer Mark II, Endocator,
Apex Finder, Digipex,
Dentometer, etc.
Third generation Apex Locator: frequency
dependent
• 3rd generation apex locators are also impedance dependent, but
they use multiple frequencies alternate current.
• The impedance or opposition of a given circuit is influenced by the
frequency of the current flow
• In biologic settings, the reactive component facilitates the flow of
higher frequency alternate current more than the lower frequency.
• Since 3rd generation devices measure the relative magnitude of
impedances against different frequencies AC current , they may also
be termed as “comparative impedance” type.
• The difference in impedance is least in the coronal part of the canal,
as the file goes deeper into the canal, difference increases & it is
greatest at CDJ. This magnitudes of impedance difference is
measured and converted into length information.
3rd generation-

• Advantages: • Disadvantages:
– Easy to operate – Needs fully charged
– Can operate in fluid battery
environment – Sensitive to canal fluid
– Uses K-type files level
– Low voltage current is
used
Various 3rd generation apex locators:
• Apit/ Endex and Root ZX are
most commonly used in
clinical practice and have been
used for several studies
• The Endex/Apit : Osada
Electric co., Tokyo, Japan
– In Europe and Asia this device
is available as Apit.
– It operates most accurately
when the canal is filled with
electrolyte such as saline or
sod. Hypochlorite.
– The disadvantage is that the
device needs to be “reset” or
“calibrated” for each canal.
Root ZX: J. Morita Co., Tokyo Japan
– This device uses dual-
frequency AC and comparative
impedance principal.
– It simultaneously measures
two impedances at two
frequencies (8 &0.4 kHz) inside
the canal
– It mainly detects the change in
electrical capacitance that
occurs near the apical foramen.
– Advantages are that it requires
no adjustment or calibration
and can be used when the
canal is filled with strong
electrolyte or when the canal is
empty and moist.
• There are several other 3rd generation EAL
used worldwide:
– Justy II, Mark V plus, Endox, Apex Finder, ProPex
4th generation:

• It measures the resistance

and capacitance separately
and compare them to
determine the distance to
the apex of the root canal.
• Bingo 1020/ Ray-Pex 4:
– The Bingo 1020 (Forum
Engineering Technologies,
Israel) claims to be a 4th
generation device
– It uses two separate
frequencies 0.4 and 8kHz.(
one at a time)
– This unit is now marketed by
Dentsply as the Ray-Pex 4.
5th generation
6th generation:

• Adaptive apex locator

continuously defines
humidity of the canal
and immediately adapts
to dry or wet canals
Combination of apex locator with endodontic
handpiece :

• Tri-Auto ZX and the

Dentaport ZX are the
combination of apex locator
and endodontic handpiece.

Tri-Auto ZX

Dentaport ZX
Advantages of Apex Locator:

• These devices are portable, light weight and easy to use.

• Less time consuming
• Additional radiation to the patient can be reduced.

• Apex locators are specially useful in situations where the

apices are superimposed by anatomic structures, or when the
use of radiograph is limited because the patient is pregnant,
handicapped, sedated, or has a extreme gag reflex
Problems Associated with the use of Electronic apex
Locator:
 Cannot be used solely for WL determination, as
incorrect reading may occur.
 Incorrect readings in situations:
 Battery too low
 Intact vital tissues, inflammatory exudates, or blood can
conduct electric current can may give incorrect reading
 Canal may be too wet or leakage of saliva inside the canal
 Blockage may be present
 Presence of metallic restoration or instrument in other
canal can affect the performance.
 Can interfere with the function of artificial cardiac
pacemaker
 The size of the apical foramen also has an influence
on electronic length determination.
  Immature or ‘blunderbuss’ apices tend to give short
measurements electronically when the instrument does
not touch the apical dentine walls (Berman & Fleischman
1984, Wu et al. 1992),(Hu¨lsmann & Pieper 1989).
 Lack of patency of the canal due to the accumulation of
dentine debris and calcifications can affect accurate working
length determination with electronic apex locator because
dentine act as insulator (Aurelio et al. 1983, Morita 1994).
• Costly instrument.
 Some facts regarding the use of Apex Locator:
• The first two generations of EAL were sensitive to the content of the canal
and irrigants. But most studies have reported that canal irrigants do not
affect 3rd generation EAL’s accuracy. ( irrigants should fill only the canal,
not the pulp chamber)

• Ebrahim et al evaluated four 3rd generation EALs to determine the WL in

teeth with various foramen diameters. They reported that as the
diameter of the apical foramen increased, the length measured with small
size files become shorter. [Aust Dent J 2006;51:258-262]
• This suggests that the size of the root canal diameter should be estimated
first and then a snugly fitting file should be chosen for root canal length
determination.

• It has been suggested in various studies that preflaring of the root canals
as used in modern crown-down preparation techniques would increase
the accuracy of readings.
Cardiac pacemaker and EALs:
• Electromagnetic interference from dental equipment
including EALs has the potential to interfere with cardiac
pacemakers.
– Woolley et al. 1974
• The manufacturers of EALs specially warn against their use
with patients with cardiac pacemaker.
• In 2002, Garofalo et al. reported that four out of five 3rd
generation EALs tested with a single cardiac pacemaker
showed normal pacing and only one produced an irregular
pace recording on an oscilloscope.
• All modern pacemakers are shielded in a hermetically sealed
metal case with capacitors that effectively filter out EMI
signals. Still it would be wise to consult with the patients
cardiologist prior to the use of EAL.
Other uses of apex locator:

 To detect root perforations

 Suspected periodontal or pulpal perforation during pinhole

preparation can be confirmed

 Diagnosis of external and internal resorption.

 Detection of horizontal and vertical root fracture.

 Any connection between the root canal and the PDL space (such as
perforations, root fracture , cracks and internal and external
resorption ) will cause the instrument to complete a circuit and
indicate that, the instrument is beyond the apex.
 LOSS OF WORKING LENGTH
 The loss of the working length during cleaning &
shaping is a frustrating procedural error.
 This happens due to:
 Failure to maintain foramen patency
 Accumulation of debris in apical portion of the canal
 Skipping instrument sizes
 Failure to irrigate the apical third effectively
 Ledge formation
 Instrument separation
Loss of working length…

• The working length may also be shorten when a curved canal

is straighten by instrumentation.
• For this reason the working length should be reassessed after
completion of apical preparation.
Conclusion:
• No individual technique is truly satisfactory in determining
endodontic working length.
• As the radiograph is a two dimensional presentation of three
dimensional figure, it can not be accurate all the time.
• Modern EALs can determine the apical terminus accurately in
greater than 90% of cases, but still have some limitations.
• Correct knowledge of apical anatomy and the prudent use of
the combination technique using EAL and radiographs will
assist us to achieve predictable results
References:
• Ingle’s ENDODONTICS 6
• Cohen’s PATHWAYS of the PULP
• ENDODONTIC THERAPY by Franklin S. Weine
• Grossman
• Osama S Alothmani et al. “Radiographic assessment of endodontic
working length: Soudi Endodontic Journal:2013 vol.3,p57-64
• The fundamental operating principles of electronic root canal length
measurement devices: M. H. Nekoofar et al. International Endodontic
Journal; 39; 595-609: 2006
• Electronic apex locators: M.P.J. Gordon & N. P. Chandler; International
Endodontic Journal 2004; 37, 425-437.
• Electronic Apex Locators – A Review: Aqeel Khalil Ebrahim et al. J Med
Dent Sci 2007; 54:125-136