doi:10.1111/iej.
12032
REVIEW
Determination of working length for teeth with
wide or immature apices: a review
Y.-J. A. Kim & N. P. Chandler
Department of Oral Rehabilitation, School of Dentistry, University of Otago, Dunedin, New Zealand
Abstract
Kim Y-JA, Chandler NP. Determination of working length
for teeth with wide or immature apices: a review. International
Endodontic Journal, 46, 483–491, 2013.
Practitioners face several challenges during the root
canal treatment of teeth with wide or immature api-
ces, one of which is working length determination.
There is relatively little data regarding the value of
radiography and electronic apex locator (EAL) use
when root formation is incomplete, and supplemen-
tary measurement techniques may be helpful. This
review considers length determination for canals
with wide or completely open apices in permanent
and primary teeth. The Ovid Medline, Web of Sci-
ence and Scopus databases were searched individu-
ally and in combinations to August 2012 using the
subject headings ‘working length determination’ and
‘open apex’ and revealed only one article. Further
headings, ‘tooth apex’, ‘apical constriction’, ‘resorp-
tion’, ‘foramen size’, ‘mature root apex’, ‘immature
Introduction
A primary goal in root canal treatment is to reduce
intraradicular microorganisms to a level below that
necessary to induce or sustain apical periodontitis
(Siqueira & R^oßcas 2008). An essential prerequisite is
establishment of correct working length during root
canal preparation, as failure to do so may result in
accidental extrusion of irrigant, dressing or filling and
Correspondence: Nicholas Chandler, School of Dentistry, Uni-
versity of Otago, PO Box 647, Dunedin 9054, New Zealand
(Tel.: 0064 3 479 7124; fax: 0064 3 479 5079; e-mail: nick.
chandler@otago.ac.nz).
© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd
root apex’, ‘working length determination’, ‘apexifi-
cation’, ‘open apices’, ‘open apex’, ‘open apical
foramina’, ‘canal length determination’, ‘immature
teeth’, ‘apical diameters’, ‘electronic apex locators’,
‘primary teeth’, ‘treatment outcome’ and ‘clinical
outcome’ were entered. Potentially useful articles
were chosen for a manual search of bibliography as
well as a forward search of citations. Other investi-
gations revealed case reports and some research
related to open apices and laboratory studies evalu-
ating EALs, radiography and tactile methods. Some
involved permanent teeth of various apical diameters
and primary teeth with and without resorption.
There is a need to define the term ‘open apex’. Clini-
cians should be aware of the benefits and limitations
of all canal measuring techniques involved in man-
aging this problem.
Keywords: endodontics, immature apex, open
apex, root canal preparation, working length.
Received 1 March 2012; accepted 18 October 2012
persistent periapical inflammation and postoperative
pain (Yusuf 1982, Georgopoulou et al. 1986). The
importance of working length control is evident in
ogren et al. 1990, Ng et al.
epidemiological studies (Sj€
2008), and histological evidence confirms that opti-
mal healing is obtained when there is minimal con-
tact between canal filling material and periapical
tissue (Ricucci & Langeland 1998).
An ‘open apex’ is found as a developmental stage
in the permanent and primary dentition, as a sequel
to pulp death following trauma or caries, or as a
result of pathological or physiological resorption of
primary teeth due to eruption of the permanent suc-
cessor (Gutmann & Heaton 1981). It may also be
iatrogenic, the result of overinstrumentation or root
International Endodontic Journal, 46, 483–491, 2013 483
 Working length for teeth with wide or immature apices Kim & Chandler
resection (Bogen & Kuttler 2009). The term open
apex is often used to describe an exceptionally wide
apical foramen, in which preparation of an apical
‘stop’ is difficult, if not impossible to achieve. The defi-
nition of open apex varies according to authors and is
reflected by the minimum ISO size used to describe it:
ISO 40 (Mente et al. 2009), ISO 45 (Van Hassel &
Natkin 1970), ISO 60 (Sarris et al. 2008, ElAyouti
et al. 2009), ISO 80 (Friend 1966, Moore et al. 2011)
or ISO 100 (Andreasen & Andreasen 2000). With
these sizes, a root canal file can be passed freely
through the apical foramen, and there may be radio-
graphic evidence of open apex (Moore et al. 2011).
Although the exact landmark for termination of
root canal treatment remains controversial, there is
general agreement that the apical constriction
is appropriate (European Society of Endodontology
2006). The apical constriction is considered to be the
narrowest region of the apical portion of the root
canal system (Dummer et al. 1984). However, it is
not always present in cases of root resorption associ-
ated with pulp and periapical pathosis, or in teeth
with open apices (Friend 1967, Dummer et al. 1984,
Laux et al. 2000). Most studies that have evaluated
the anatomy and diameters of apical constrictions are
confined to the fully developed apices of permanent
teeth, with pathological condition unstated and with
limited age groups or sample size (Kuttler 1955,
Dummer et al. 1984). There is little information
regarding the anatomy of incomplete apices. In a
radiographic analysis of the immature permanent
teeth of 7.5–15-year-olds, Friend (1966) described
three types of open apices: divergent, parallel and
tapering. He stated that as root development in the
labio-lingual plane lags behind that in a mesio-distal
direction, a parallel apex seen on a radiograph would
appear more divergent if the image could be taken
proximally. He concluded that it is impossible to thor-
oughly instrument the apical portion of these canals
(Friend 1967). This is supported by others, who sug-
gest difficulties in chemomechanical preparation and
filling of such canals may lead to residual infection
(Pinar Erdem & Sepet 2008). Steiner et al. (1968)
went further, suggesting that instrumentation of the
apical portion of these canals must be avoided to pre-
vent thinning of their fragile dentinal walls. Approxi-
mate working lengths determined radiographically
would suffice. More reliance might be placed in the
use of calcium hydroxide dressings to disinfect the
canal and prevent the consequences of overzealous
instrumentation of thin dentine walls (Sj€ ogren et al.
484 International Endodontic Journal, 46, 483–491, 2013
1991, Mente et al. 2009). There is therefore a need
for clinical guidelines for working length determina-
tion in teeth with open apices.
Working length determination for open
apices
The European Society of Endodontology (2006) rec-
ommends the use of an electronic apex locator (EAL)
followed by confirmation of canal length with an
undistorted radiograph during root canal treatment. If
the instrument in the canal appears to be more than
3 mm from the radiographic apex, the working
length needs to be adjusted. Although radiography is
the main method of selecting working lengths during
the treatment of teeth with open apices, case reports
and clinical trials have reported variations in tech-
nique. Numerous researchers recommend Ingle’s
(1957) method, the radiographic estimation of the
working length 1–2 mm short of the radiographic
apex determined from a pre-operative radiograph or
from tactile sense (Ingle 1957, Friend 1966, Duell
1973, Gilbert 1983, Dummer et al. 1984), whilst Van
Hassel & Natkin (1970) instrumented to the radio-
graphic apex during treatment of immature perma-
nent teeth with open apices. Several reports have
mentioned the use of radiographs for length determi-
nation but did not elaborate further (Frank 1966,
Sarris et al. 2008, Yassen et al. 2012). Whitworth &
Nunn (2001) suggested preparing the canals 2–3 mm
short of an estimated working length obtained from
an undistorted pre-operative periapical radiograph.
Moore et al. (2011) reported using both conventional
radiographs and an EAL. Omitting local anaesthesia
has also been suggested, as any sensitivity or haemor-
rhage may indicate the need to adjust file length
(Friend 1966, Duell 1973).
Despite radiographs being the key method of deter-
mining working lengths, there are several factors
influencing their accuracy (Andreasen & Andreasen
1985, Tidmarsh 1987, Mentes & Gencoglu 2002).
Paralleling techniques produce more reliable tooth
length determination than the bisecting angle method
(Forsberg 1987). However, in a laboratory study by
ElAyouti et al. (2001), the authors found that radio-
graphic lengths 0–2 mm short of the radiographic
apex led to file positions beyond the apical foramen in
22–51% of cases in molars and pre-molars, but not in
anterior teeth. Combining the use of EALs with radio-
graphs was recommended in a subsequent paper to
avoid over-instrumentation (ElAyouti et al. 2002). In
© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd
 Kim & Chandler Working length for teeth with wide or immature apices
fact, the use of the paralleling technique can result
in an up to 7.58% over-estimation of the actual
canal length (Mentes & Gencoglu 2002); thus, with
radiographs, there is the potential for unintentional
over-instrumentation.
Anatomical noise, such as the superimposition of
the maxillary sinus and zygomatic arch, can influence
the accuracy of working length, especially if the
bisecting angle technique is used (Tamse et al. 1980,
ElAyouti et al. 2001). In addition, variables, such as
the shape and orientation of the apex in relation to
the X-ray beam, observer variability, film speed, and
viewing conditions, such as the presence of extrane-
ous light, can all influence the accuracy of radio-
graphic working length determination (Olson et al.
1991, Stein & Corcoran 1992, Sheaffer et al. 2003,
Orafi et al. 2010). As Dummer et al. (1984) sug-
gested, a combination of methods increases the accu-
racy of length determination.
Use of electronic apex locators
With the development of EALs, assessment of working
length has become more predictable, reducing some
shortcomings of radiographs and the number taken
during treatment (Brunton et al. 2002, Chandler &
Koshy 2002). Use of an EAL may prevent uninten-
tional over-instrumentation (Stein & Corcoran 1992,
ElAyouti et al. 2001, Ravanshad et al. 2010). Despite
having an accuracy of 80–90% in most root canals
(Gordon & Chandler 2004), their performance can be
limited by multiple factors: presence of a nearby
metallic restoration or vital tissue, the type of any
electrolytes in the canals, the diameter of the apical
foramen, an absence/presence of apical constriction
and the size of file in use (Berman & Fleischman
1984, Goldberg et al. 2002, Lee et al. 2002, Fan et al.
€
2006, Ozsezer et al. 2007). Berman & Fleischman
(1984) recognized the limitations of first generation
devices in teeth with immature apices in their in vitro
study. This was confirmed in a laboratory study by
H€ulsmann & Pieper (1989) using a second generation
EAL (Exact-a-pex, Ellman, New York, NY, USA). They
observed that all EAL readings were short of actual
working length in cases of immature permanent teeth
with apical foramina exceeding size 50. Although
third-generation EALs were designed to overcome
some of these limitations (Fouad et al. 1993), the api-
cal foramina diameters above which canal measure-
ments became unreliable vary: > size 60 (Ebrahim
et al. 2006a, Herrera et al. 2007), > size 80 (Ebrahim
© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd
et al. 2006b) and > size 90 (ElAyouti et al. 2005,
Herrera et al. 2011). Some differences may be due to
the settings in which the experiments took place and
the EAL used. Additionally, caution is necessary when
interpreting laboratory studies as there may be no
reason given for the extraction of the teeth used or
any apical disease present. The presence or type of
tissue in the canal may influence the accuracy of the
Root ZX (J. Morita Mfg. Corp., Kyoto, Japan). In a
clinical study, Dunlap et al. (1998) found two read-
ings in their necrotic group were 1.5 mm beyond the
apical constriction. Such findings might be due to api-
cal resorption in the extracted teeth (Goldberg et al.
2002).
A number of laboratory studies have reported that
irrigants do not affect the accuracy of modern EALs
(Vajrabhaya & Tepmongkol 1997, Kaufman et al.
2002, Meares & Steiman 2002). However, the ability
to operate reliably with electrolytes varies and is
dependent on the type of moisture present in the
canals and the size of the file relative to that of the
apical foramen. The Root ZX was developed in 1994
to help reduce electro-conductivity within the canal
associated with electrolytes or vital pulp tissue (Ko-
bayashi & Suda 1994). Nevertheless, blood in the
canal appears to adversely affect its readings, espe-
cially when smaller files were used in canal sizes 40–
80 (Ebrahim et al. 2006b). On the other hand, in the
presence of 6% sodium hypochlorite (NaOCl), the
Root ZX was not significantly influenced by smaller
files, irrespective of canal sizes from 40 to 80. When
a size 10 file was used in canals prepared to size 80,
the largest discrepancies were 0.19 and 1.11 mm in
groups irrigated with NaOCl and human blood respec-
tively. In other words, without blood and possibly
serum or pus, relatively reliable working lengths can
be obtained with the use of the Root ZX in canals
containing NaOCl prepared to size 80 regardless of
the dimensions of the measuring file. By contrast, Fan
et al. (2006) using glass tubes of different diameters
to mimic root canals found 2.5% NaOCl had a signifi-
cant impact on the accuracy of the Root ZX, whilst
the Neosono Ultima EZ (Amadent, Cherry Hill, NJ,
USA) remained unaffected. Interestingly, three-third-
generation EALs showed substantial variations in the
differences between the real lengths and the measured
lengths when the tube diameters were 0.80–1.00 mm.
In the presence of 2.5% NaOCl, the measurement errors
displayed were 5.65  1.84 mm, 0.83  0.36 mm,
0.4  0.13 mm, respectively, for TriAuto ZX (J. Morita),
ProPex (Dentsply Maillefer, Ballaigues, Switzerland) and
International Endodontic Journal, 46, 483–491, 2013 485
 Working length for teeth with wide or immature apices Kim & Chandler
Neosono Ultima EZ. Caution is needed when interpreting
such findings as the impedance ratio measurements may
be influenced by conducting media.
A snug-fitting file is recommended to measure
working lengths especially in the presence of blood
(Stein et al. 1990, Ebrahim et al. 2006b). However,
several laboratory studies show that file sizes from 10
upwards did not make a difference for apical constric-
tion diameters up to size 60 using the Root ZX (Saito
& Yamashita 1990, Nguyen et al. 1996, Herrera et al.
2007). The Root ZX proved unreliable with a size
100 apical constriction, with mean measurement
errors ranging from 0 to 1.03 mm, and it was not
clear whether better fitting files (size 100) gave more
reliable readings (Herrera et al. 2007). Ebrahim et al.
(2006b) noted that beyond size 80, there was a mea-
surement error of 2.24 and 0.88 mm with the use of
size 10 and 80 K-files, respectively, using the Root ZX.
The Apit 7 (Osada Electric Co, Tokyo, Japan), on the
other hand, gave the largest measurement errors of
2.84 and 1.61 mm (Ebrahim et al. 2006b). The Root
ZX performed significantly better than the other three
EALs tested in this study. Nevertheless, the measure-
ment error increased when apical size 150 was evalu-
ated, with the Root ZX showing errors of 5.12 and
2.14 mm, respectively. A recent laboratory study by
Herrera et al. (2011) using the Root ZX revealed that
regardless of file size, it was accurate for an apical size
of 60, whereas better fitting files (minimum 45) should
be used for apical sizes from 70 and 80. All in all,
within a tolerance of 1 mm, the accuracy was in the
range of 95–99% for all diameters of apical foramina.
Nevertheless, above size 90, this EAL was inaccurate
(Herrera et al. 2011).
It appears that not all EALs are able to prevent
over-instrumentation (ElAyouti et al. 2005). These
workers compared three instruments, the Root ZX,
Raypex®4 (VDW GmbH, Munich, Germany) and the
Apex Pointer (Micro Mega, Besancßon, France), in
resected root-ends with sizes of apical terminus vary-
ing from 50 to 90 and using a size 15 measuring file.
It was found that none of the readings with the Root
ZX resulted in overestimation of the working length,
whilst 4% of readings with the Raypex®4 and the
Apex Pointer did. Although there were statistically
significant differences between the readings at apical
terminus sizes 50–60 and 70–90, with the means
ranging from 0.27 to 0.38 mm between the two
groups, it appears that the difference is clinically
acceptable. Clearly, the results from laboratory studies
need to be interpreted with caution, as in clinical
486 International Endodontic Journal, 46, 483–491, 2013
situations, there is often a lack of ideal circumstances
for precise measurement (Beltrame et al. 2011).
Alternative measurement of working
length for open apices
Several studies have investigated other methods of
working length measurement for teeth with open api-
ces. Baggett et al. (1996) evaluated a tactile tech-
nique using paper points and claimed it to be
comparable to radiography and unaffected by the size
of the apex or the presence of periapical pathology.
The technique involved using a size 30 paper point
placed in the canal and advanced until resistance was
felt. The authors found that this method was accurate
to within 1 mm of the radiographic diagnostic length
95% of the time and concluded that a working length
radiograph was unnecessary when this method was
employed. A shortcoming of the technique is that if
periapical soft tissues extend into the canal, underesti-
mation of the working length could result. Up to
3 mm of soft tissue was present in two of 35 cases
studied (Baggett et al. 1996). Additionally, there is
the potential for overfill when the level of the apical
terminus, affected by pathological resorption, is
uneven. This may not be evident radiographically,
especially if the shorter aspect is in the bucco-lingual
direction. To overcome this problem, ElAyouti et al.
(2009) proposed a tactile method involving the use of
a size 25 K-file bent at the tip, with its orientation
marked with a silicone ring. The file was bent to facil-
itate ease of use. This method may be restricted to rel-
atively straight canal curvatures (<10 degrees).
Clinical trials are needed to further assess this
method, especially in curved canals.
Although never proven accurate for open apices, the
paper point technique described by Rosenberg (2003)
to supplement initial EAL readings could be considered
for the working length determination of open apices in
relatively straight canals (  10 degrees). The tech-
nique is described as follows: given that the canal is
dry, an initial paper point is placed 0.5 mm short of the
EAL indicated length. If the point comes out dry, it is
advanced apically in the canal in small increments
(0.25 mm) under magnification until some fluid is
picked up. Another paper point is used just short of this
point, and the working length is then the maximum
length that a point can be placed into the canal and
remains dry. Rosenberg (2003) cautioned that the
paper point should only remain in brief contact before
any capillary action has taken place. A study using
© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd
 Kim & Chandler Working length for teeth with wide or immature apices
teeth of unknown periapical status validated this
method using micro-computed tomography (Marcos-
Arenal et al. 2009). Following paper point assessment
and tooth extraction, files were positioned and imaged,
and the method found to be reliable in straight canals.
It was 87% accurate to within  0.5 mm of the apical
foramen, with high repeatability. However, prerequi-
sites included a dry canal and wet periapical tissue,
which were not obtainable in eight of the 84 canals in
the study.
Working lengths and outcomes
Epidemiological evidence suggests that a favourable
outcome is associated with a root filling placed within
0–2 mm of the radiographic apex, with overfilling or
underfilling adversely affecting outcome if infection is
present (Sj€ ogren et al. 1990, Negishi et al. 2005).
According to Negishi et al. (2005), teeth that featured
apical periodontitis where the apical constriction
could not be determined by an EAL had a five times
greater risk of failure. In this group, the distance from
the apex varied from less than 2 mm to more than
2 mm, with the mean distance 3.95 mm from the
radiographic apex. The largest master apical file used
was greater than size 40. It seems that regardless of
the size of the apical canal, the presence of apical
periodontitis pre-operatively and inability to control
infection to the full working length play significant
roles in the treatment outcome. As contemporary root
filling materials are either biocompatible or induce
temporary cytotoxicity prior to setting, it is unlikely
that failures would occur as a result of overfilling
without infection (Bystr€ om et al. 1987, Sj€ogren et al.
1997, Shabahang et al. 1999, Felippe et al. 2005).
Infected, overfilled root canals are often associated
with poor marginal adaptation and apical seal,
which may allow nutrients from the periapical tissue
to reach remaining bacteria to sustain infection.
Extruded infected dentinal debris also leads to the per-
petuation of apical periodontitis (Sarris et al. 2008).
Schaeffer et al. (2005) in their meta-analysis evaluat-
ing optimal obturation length concluded that it
should be 0–1 mm short of the radiographic apex, as
overfill may decrease the prognosis for repair.
Clinical studies evaluating the outcome of healing
in teeth with open apices filled with MTA show
favourable results (Simon et al. 2007, Holden et al.
2008, Witherspoon et al. 2008, Moore et al. 2011).
Sarris et al. (2008), who followed up 17 treated inci-
sors for up to a year on average, found no association
© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd
between the apical limit of MTA and success. Subse-
quently, Moore et al. (2011), who treated 22 incisors
and had an average follow-up period of 2 years,
found a strong association between MTA plug posi-
tion and treatment outcome. The ideal MTA position
was not defined but was reported in 63.6% of cases,
whilst 9.1% were underfilled and 27.3% were over-
filled. A nondivergent apical shape facilitated ideal
positioning of the plug, and these teeth were associ-
ated with a more favourable outcome. The authors
suggested that the use of an apical barrier might have
improved the position of the plug, especially in diver-
gent canals. The potential role of the apical limit of
filling material in the long-term outcome of canals
with open apices with contemporary materials war-
rants further investigations.
Primary teeth
The apical extent of the root canal system of primary
teeth is difficult to determine (Goerig & Camp 1983,
Rimondini & Baroni 1995). Physiological resorption
may be complicated by pulp and periodontal inflam-
mation, and it is essential to minimize potential
damage to the permanent successors (Holan & Fuks
1993, Coll & Sadrian 1996). Extruded root canal
fillings have a lower success rate than if the root fill-
ing is short or to the apex in primary teeth (Coll &
Sadrian 1996). There is general consensus that root
canal treatment is contraindicated in primary teeth
displaying root resorption of more than one-third of
the root.
Several clinical studies have evaluated the accuracy
of third-generation EALs in primary teeth with and
without resorption, demonstrating the efficacy of this
method (Kielbassa et al. 2003, Beltrame et al. 2011,
Odabas et al. 2011). According to Kielbassa et al.
(2003), using a group of primary teeth (34 molars,
37 incisors) with and without resorption, the Root ZX
was accurate to within 1 mm in 64% of cases. No
influence of type of tooth or presence or absence of
root resorption was noted. This finding was in agree-
ment with the clinical study by Odabas et al. (2011),
who concluded that the Root ZX had high accuracy
(86.35–95.82% within 1 mm) irrespective of presence
or absence of root resorption, and a study by Beltrame
et al. (2011) who found the Root ZX to be highly pre-
dictable in primary molars with varying levels of
resorption. Interestingly, in up to 7.7% of the teeth, the
Root ZX had overestimated the working length by more
than 1 mm (Beltrame et al. 2011).
International Endodontic Journal, 46, 483–491, 2013 487
 Working length for teeth with wide or immature apices Kim & Chandler
Overall, laboratory studies have supported the use
of EALs in primary teeth with root resorption (Mente
et al. 2002, Ghaemmaghami et al. 2008, Leonardo
et al. 2008, Tosun et al. 2008, Bolan & Rocha 2010,
Mello-Moura et al. 2010, Nelson-Filho et al. 2010).
Tosun et al. (2008) compared the performance of the
Root ZX and the Tri Auto ZX with file size 15 and
found their respective accuracy to be 98.2% and
100%, which, being in a laboratory setting, are
expected to be higher than the results from clinical
studies (Kielbassa et al. 2003, Beltrame et al. 2011).
The presence of root resorption had more influence
on the accuracy of the Tri Auto ZX than the Root ZX,
whilst in the study of Bolan & Rocha (2010), there
was no significant difference between two EALs tested,
the Root ZX and Apex Pointer, despite the presence
or absence of resorption. In a laboratory study in
extracted primary teeth displaying root resorption of
up to one-third of root length Angwaravong & Pani-
tvisai (2009) confirmed the accuracy of the Root ZX,
96.7% within 0.5 mm when files 15–40 were used.
On the other hand, Bodur et al. (2008) found neither
of the EALs they tested, the Root ZX and Endex
(Osada Electric Co.) were reliable. There was no statis-
tically significant difference between primary teeth
showing resorption and those without. The authors
recommended that adjunctive methods should supple-
ment the use of EALs.
Laboratory studies have compared the ability of
conventional and digital radiography and EALs in
determining working lengths in primary teeth with or
without resorption, with varied results. EALs were
shown to be more accurate than conventional radiog-
raphy in a study by Pati~ no-Marın et al. (2011), whilst
Katz et al. (1996) showed no significant difference
between the two in primary molars with partial
resorption. However, the authors of the latter study
observed that the Root ZX identified tooth length at
the most coronal portion of the resorption, thus giv-
ing slightly shorter working lengths. Tawil (2012)
also found digital radiography and the use of Root ZX
to be comparable, and the use of tactile means to be
inferior in anterior primary teeth with resorption.
Subramaniam et al. (2005), on the other hand, did
not find significant differences between tactile meth-
ods, radiography and the Foramatron D 10 (Parkell
Electronic Division, Farmingdale, NY, USA). It is
unclear whether the teeth in their study displayed
obvious resorption.
Several investigators have suggested that despite
the presence of root resorption, EALs can still be
488 International Endodontic Journal, 46, 483–491, 2013
reliable when there is a degree of taper in the apical
canal shape (Goldberg et al. 2002, Angwaravong &
Panitvisai 2009, Odabas et al. 2011). Although stud-
ies support the use of EALs in primary teeth display-
ing physiological resorption, the relation of the extent
of the apical root resorption to the accuracy of EALs
remains to be explored. Furthermore, potential prob-
lems exist when EALs are used in cases where the
apical dimension is wider than its more coronal
aspect, precluding contact of the file with the sur-
rounding apical walls of the root canal (H€ ulsmann &
Pieper 1989). It appears that combining radiography
and the EAL when determining working lengths of
primary teeth displaying resorption should give a
more predictable result.
Conclusion
There is a need for a clear definition of what com-
prises an ‘open’ apex, and more research is necessary
on how best to image the very fine detail of root api-
ces. Clinically, owing to their limitations, the use of
EALs and radiographs should be supplemented with
other methods, especially when treating very wide
apical terminations. No long-term studies have been
carried out to evaluate supplementary techniques. In
addition, further studies are needed to show the accu-
racy of working length methods in cases of apical
resorption.
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