Working length determination in RCT

Introduction:
Determination of an accurate working length(WL)is one of the
most critical steps of endodontic therapy.the cleaning, shaping and
obturation of root canal system cannot be acomplished accurately
unless WL is determined precisely.
According to endodontic glossary :
W.L is defined as” the distance from a coronal reference point to a
point at which canal preparation obturation should terminate.”
Working Length Determination
The objective of working length determination is to establish
the length (distance from the apex) at which canal
preparation and subsequent obturation are to be terminated.
Importance of accurate working length determination:
· Confine the instrumentation to the canal system (within
dentin).
· Create and maintain an apical stop or seat at the minor
constriction.
· Prevent under- instrumentation that could leave tissue and
debris in the apical segment.
· Prevent over- instrumentation which could cause patient
discomfort, damage periapical tissue, or potentially cause an
infection or cyst development from the placement of
irritating materials beyond the apex.
  Reference point : is that site on occlusal or the incisal
surface from which measurements are made .
A reference point is chosen which is stable and easily visualized
during preparation.
 Anatomic apex: is tip or end of root determined
morphologically .
 Radiographic apex: is tip or end of root determined
radiographically.
Apical foramen: is main apical opening of root canal which may be
located away from anatomic or radiographic apex.
Apical constriction: is apical portion of root canal having
narrowest diameter .
It is usually 0.5-1mm short of apical foramen.
The Cementdentinal junction:is the region where cementum and
dentine are united ,the point at which cemental surface terminate at
or near the apex.
Different methods of WL estimation:

 Average root length from anatomic studies

 Radiographic

 Mathematics method

 Tactile sensation

 Bleeding on paper point

 Apical periodontal sensitivity

  Electronic apex locator
Radiographic method
1. Measure the estimated WL from preoperative periapical
radiograph
2. Adjust stopper of instrument to this estimated WL and place
it in the canal up to the adjusted stopper
3. Take the radiograph
4. On the radiograph measure the difference between the tip of
the instrument and the root apex add or subtract this length
to the estimated WL to get the new WL.
5. correct WL is finally calculated by subtracting 1 mm from
this new length .

Modification in the length subtraction:

1. No resorption -subtract 1mm
2. Periapical bone lesion - subtract 1.5 mm
3. Periapical bone +root apex resorption
-subtract 2 mm
Mathematic method:

 it is based on simple mathematical formulation to calculate

the WL.

 In this an instrument is inserted into the canal ,stopper is

fixed to the reference point and radiograph is taken.

The formula to calculate actual length of the tooth ia as

follow:
Actual length of tooth apperent length of tooth in
x-ray
-------------------------------- --- =
------------------------------------------------
Actual length of instrument apperent length of
instrument
in radiograph
So,
actual length of instrument X
apperent length of tooth in
radiograph
Actual length of tooth=
------------------------------------------------------------
apperent length of instrument in
radiograph
disadvantages:
Wrong readings can occur because of :
A. Variation in angles of radiograph
B. Curved root
C. S-shaped ,double curvature roots.

 Other methods of WL determination including:

 tactile sensation

 Apical periodontal sensitivity

 Paper point measurement

These methods don’t always provide the accurate readings for
example :
In case of narrow canals instrument may feel increased resistance
as file approaches apical 2-3mm and in case tooth with immature
apex instrument can go beyond apex.
So these methods should not used alone should be used as
supplement to radiographs apex locators.
Electronic method:

 The electronic method calculates the working length by

comparing the electrical resistance of the periodontal
membrane with that of the gingival surrounding the tooth,
both of which should be similar. The processors of these both
of these machines basically work on four mechanisms.
§ Log readings
§ Subtract method
§ Taking averages
§ Taking ratios

 These mechanisms are more important as compared to the

number of frequencies used to collect data, as these signify
essentially how the device interprets the data. All apex
locators function by using human body to complete a circuit.
The apex locators are also classified based on the principle
they work on.

 Suzuki conducted research in 1942 and this was used by

Sunanda

The apex locators are base on three principles:

§ Resistance method
§ Impedance method
§ Frequency ratio method
Resistance Method
(First Generation Apex Locators)

 The apex locator has a built in resistant value of 6.5 kilo

Ohms. The apex locator is attached to the patients lip on one
side and the other side is attached to the file. The file is then
advanced into the canal until it touches the periodontal tissue
at the apex which then completes the circuit.
Impedance Method
(Second Generation Apex Locators)
Operates on the principle that there is electrical impedance across
the walls of the root canal due to the presence of the transparent
dentin. The tooth exhibits an increasing electrical impedance
across the walls of the root canal, which is greater apically than
coronally. At the DCJ, the level of impedance drops dramatically.
The unit detects the sudden change and indicates it on the analogue
meter. To overcome the problem of a wet environment, insulated
are utilized.
Frequency Ratio Method
(Third Generation Apex Locators)

 Operates very similarly to the Impedance-type because it

measures the impedance of the tooth at two different
frequencies. In the coronal portion of the canal, the
impedance difference between the frequencies is constant. As
the file is advanced apically, the difference in the impedance
value begins to differ greatly with maximum difference at the
apical area.
 EAP are used for determining WL as an adjunct to
radiography.
They are basically used to locate the apical constrictions or
cementodentinal junction or apical foramen and not the
radiographic apex.
Uses of apex locator:
1. Provide high degree of accuracy
2. Useful in conditions where apical portion is obstructed.
3. Useful in patient with gag reflex
4. Pregnant patient
5. Root perforation ,resorption ,root fracture .
6. Pulp vitality
7. RCT of teeth with incomplete root formation.
Advantages of EAL:

 Accurate

 Objective measurement

 Easy and fast

 Reduction of exposure to radiation

 Perforation can be detected

 Can measure pulp space exactly to constriction

 Can detect resorption and root fracture

Basic conditions for accuracy of EAL:

 Canal should be free from debris

 Canal should be relatively dry

 No cervical leakage

 Proper contact of file with canal walls and periapex

 No blockages or calcification in canal

Contraindication of EAL:

 In patient who have cardiac pace maker,electrical stimulation

to such patient can interfere with pace maker function

 In teeth with periapical radiolucency and necrotic pulp

associated with root resorption the use of apex locator is not
much beneficial.
Summery:

 The most important to understand when determining WL is

morphology of apical one third of the canal.

 The consideration should given to adopt the parameter 0.5-

0.0mm(from apical constriction)as most ideal terminating
point in canal.

 We should use many of these techniques as possible during

the course of treatment.