Working length

and
Instrumentation
BY:
AHMED ABDULKHALIQ
HIBA MAHMOOD
ZAHRAA ALI
BAN ALAA
Introduction

 Establishing the working length is an important step in endodontic treatment as

inaccurate length determination may lead to failure. There is an ongoing debate
regarding the extent of the apical limit of root canal preparation. This controversy
is based upon different clinical opinions concerning the distance between the end
point of the root canal preparation and the periodontal tissues. we will review the
different thoughts for working length determination, and how apex locators work
and how they must be used for optimal accuracy. The technique of determining the
working length from a single radiograph remains empirical, and apex locators
should be considered an essential aid in establishing working length.
Anatomic consideration and
terminology

 Working length : the distance from

a coronal reference point to the
point at which canal preparation
and obturation should terminate.
Anatomy of root apex:
 1.Tooth apex (radiographicapex). is the tip
or end of the root determined
radiographically.
 2.Apical foramen (located away from the
anatomic or radiographic apex. major
foramen). the main apical opening of the
root canal. It is frequently eccentrically
 3.Apical constriction (minor foramen). the
apical portion of the root canal having the
narrowest diameter. This position may
vary but is usually 0.5 to 1.0 mm short of
the center of the apical foramen.
 The cementodentinal junction – the region where the
dentin and cementum are united, )the point at which the cemental
surface terminates at or near the apex of a tooth(.
 cementodentinal junction does not always coincide with the apical
constriction.
 The location of the cementodentinal junction ranges from 0.5 to 3.0
mm short of the anatomic apex.
Dummer classification of apical constriction
Significance of working length
 Determines how far into the canal the instruments are placed &
worked & thus how deeply the tissues, debris, metabolites are
removed .
 Limits the depth to which the canal filling may be placed.
 Affects the degree of pain & discomfort that the patient will feel
following the appointment.
 If calculated within correct limits, it will play an important role
in determining the success of the treatment & conversely, if
calculated incorrectly, may doom the treatment to failure.
Clinical Considerations
 Before determining a definitive working length, the coronal access to the pulp
chamber must provide a straight pathway into the canal orifice
 Loss of working length during cleaning and shaping can be a frustrating
procedural error
 It is extremely important to monitor the working length periodically since the
working length may change as a curved canal is straightened
 The loss may also be related to the accumulation of dentinal and pulpal
debris in the apical area.
 Loss of working length may also be due to ledge formation or instrument
separation and blockage of the canal.
 Most dentists agree that the desired end point is the apical
construction, which is not only the narrowest part, but a
morphological Land – Mark that can help .to improve the apical seal
 If the length being too long, this may lead to perforation through the
apical construction, with subsequent overfilling or overextension,
which mean postoperative pain, prolonged healing period
 Incomplete cleaning and filling may cause persistent discomfort, also
apical leakage may occur into the uncleaned and unfilled space short
of the apical constriction
Reference point
 is the site on the occlusal or incisal
surface from which measurements
are made.
 A reference point that will easily
visualize during preparation is
chosen. Usually this is the highest
point on the incisal edge on the
anterior teeth and a cusp tip on
posterior teeth.
 It is imperative that teeth with fractured cusps or cusps severely
weakened by caries or restoration be reduced to a flattened
surface, supported by dentin. Failure to do so may result in
cusps or weak enamel walls being fractured between
appointments. Thus, the original site of reference is lost. If this
fracture goes unobserved, there is the probability of over
instrumentation
Methods for determination of
Working length
 Working length by Radiographs
 Working length by Apex Locators
 Working length by tactile sensation
 Working Length by Paper point test
Radiographic method

• An estimate of the approximate length of the tooth is made from a preoperative

parallel radiograph
 A file is placed in the root canal about 1 mm short of this estimated length
ensuring that a coronal reference point is selected that is reproducible, stable
and durable
 The file should be large enough to be visible on the
radiograph (e.g. size 10 but size 08 may also suffice)
 A parallel radiograph is then taken
 In teeth with multiple canals, diagnostic files should
be placed in all canals and a single view taken
to minimize exposure to radiation actual and radiographic distance between the
tip of the file and the reference point indicated by the rubber stop
 In most cases, the tip of the file will be short of the radiographic apex
 This is often accepted as the length of the canal if the distance is within 1 mm
 If the discrepancy is greater than 1 mm, then the distance between the file tip
and the radiographic apex should be measured and 1 mm subtracted from
this measurement (as in the central incisor)
 This residual discrepancy is added to the length of the diagnostic file to give
the estimated length of the canal
 In some cases, the file may be longer than the radiographic apex, in which
case the distance between the file tip and a point 1 mm short of the
radiographic apex should be measured
Working length by Apex Locators
 Electronic apex locators in theory enable the location of the true position of the
apical terminus, utilizing the fact that root canals, in common with other tubes
with one end immersed in an electrolyte solution, exhibit certain electrical
characteristics that are relatively constant
 Impedance value at the apical foramen that is between the periodontal ligament
and the oral mucosa, measured via the root canal is a relative
constantFunctioning of EAL
 EALs work by applying an alternating current between two electrodes, one of
which is attached to the file and the other via a clip to the lip or cheek mucosa
 The frequency of this current, which also influences impedance, is usually fixed in
a given make of instrument but differs between makes
 As the file is passed down the canal, the EAL measures the impedance and
compares the value with its calibrated standard
 A countdown scale indicates a “zero” or “apex” reading when the calibrated value
is matched • All currently available conventional EALs use this principle but
display the information differently
 The current generation of EALs has overcome the problem with electrolytes in
root canals by measuring the impedance at multiple current frequencies
 The Root ZX (J Morita, Kyoto, Japan) compares the ratio of impedance at two
frequencies to derive the apical position
 The Elements Diagnostic Unit (SybronEndo) ( fourth generation apex locator)
measures resistance and capacitance separately rather than the resultant
impedance
 The Raypex® 5 (VDW) which also uses multiple frequencies, claims to be a fifth
generation apex locator with greater accuracy
Electric endodontic handpiece with
built-in root ZX apex locator
It has three safety mechanisms:
 Autostart-stop mechanism: Handpiece starts rotation when instrument
enters the canal and stops when it is removed.
 Autotorque-reverse mechanism: Handpiece automatically stops and reverses
rotation when torque threshold exceeds. It prevents instrument breakage.
 Autoapical-reverse mechanism: It stops and reverses rotation when
instrument tip reaches a distance from apical constriction taken for working
length. It prevents apical perforation. Endy 7000 reverse the rotation when
tip reaches the apical constriction. Sofy ZX (J. Morita Calif ) uses Root ZX to
electronically monitor the location of file tip during the entire
instrumentation procedure.
Basic Conditions for Accuracy of EALs

Whatever is the generation of apex locator, there are some basic conditions,
which ensure accuracy of their usage.
 Canal should be free from most of the tissue and debris
 Apex locator works best in a relatively dry environment. But extremely dry
canals may result in low readings, that is, long working length
 Cervical leakage must be eliminated and excess fluid must be removed from
the chamber as this may cause inaccurate readings
 If residual fluid is present in the canal, it should be of low conductivity value,
so that it does not interfere the functioning of apex locator
 Descending order of conductivity of various irrigating
 solutions is
 • 5.25% NaOCl > 17% EDTA > saline
 Since EALs work on the basis of contact with canal walls and periapex.
Better the adaptation of file to the canal walls, more accurate is the reading
 Canals should be free from any type of blockage, calcifications, etc.
 Battery of apex locator and other connections should be proper
Advantages of Apex Locators

 Devices are mobile, light weight and easy to use

 Much less time required
 additional radiation to the patient can be reduced (particularly
useful in cases of pregnancy)
 80 - 97 % accuracy observed
Disadvantages of Apex Locators
 Can provide inaccurate readings in the following cases:
–– Presence of pulp tissue in canal
–– Too wet or too dry canal
–– Use of narrow file
–– Blockage of canal
–– Incomplete circuit
–– Low battery
 Chances of overestimation
 May pose problem in teeth with immature apex
 Incorrect readings in teeth with periapical radiolucencies and necrotic pulp
associated with root resorption, etc. because of lack of viable periodontal
ligament
Tactile method

 Tactile sense alone can be used to gauge the position of the apical terminus – Not all
teeth possess an apical constriction due to the presence of apical resorption caused by
apical periodontitis –

 Second, the ability to gauge the apical constriction relies on the preexistence of a
natural canal taper that has a minimal constriction only at the termination of the
canal (four distinct patterns of apical constriction)

 Third, the tactile detection of the apical constriction relies upon the selection of a file
size that will first bind only at the apical constriction
Advantages
 Time saving
 No radiation exposure

Disadvantages
 Does not always provide the accurate readings
 In the case of narrow canals, one may feel increased resistance as file
approaches apical 2–3 mm
 In the case of teeth with immature apex, instrument can go periapically
Paper-point method

 • Use of a sequence of paper points that show the position of the apical
foramen by virtue of the junction of tide-mark of the blood-wetted and dry
tip of the • it is unreliable by itself because of seepage of exudate or blood into
the canal and by capillary action along the paper point paper point
 A new dimension has recently been added to .paper points by the addition of
millimeter markings. These paper points have markings at 18,19,20,22 and
24mm from the tip
 Modification of length
 substraction in case of Resorption
Working length distance from the apex is determined when the following are seen
 radiograpbically
 -No bone or root resorption: 1 mm from apex
 -Bone but no root resorption: 1.5 mm from apex
 -Bone and root resorption: 2 mm from apex

Failure to accurately determine &
maintain working length
 a- Length too long can lead to :

 1. Perforation through apical constriction 2.

 2. Overfilling or over extension

 3. Increased incidence of post operative pain.

 4. Prolonged healing period.

 5. Lower success rate, owing to incomplete regeneration of Cementum, Periodontal

ligament and Alveolar bone .
 b- Short working length can lead to :
 1. Incomplete cleaning
 2. Underfilling
 3. Persistant discomfort
Summary & Conclusion

 • The cementodentinal junction or minor diameter is a practical and anatomic

termination point for the preparation and obturation of the root canal – and
this cannot be determined radiographicaly.
 • Modern apex locators can determine this position with accuracies greater
than 90% but with some limitations.
 • No individual method is truly satisfactory in determining endodontic working
length.
 • Therefore, combination of methods should be used to assess the accurate
working length determination
instrumentation

The root canal system must be:

 Cleaned of its organic remnants
 Shaped to receive a three dimensional filling of the entire root canal space
 Canals should be instrumented neither too short nor too long
 It is believed that the apical termination of the intervention should be at the
apical constriction because this location indicates the junction between the
periodontal and pulpal tissues.
Traditional Concept

For many years, two guidelines were considered for instrumentation:

 1. Enlarge the root canal at least three sizes beyond the first instrument that
binds the canal
 2. Enlarge the canal until it is clean. It is indicated by white dentinal shavings
on the instrument flutes.
 However, these guidelines are not considered sole criteria in all the cases. The
color of dentinal shavings is not indication of presence of infected dentin. An
ideal enlargement should provide debris removal throughout the canal and
facilitate irrigation to the level of minor constriction.
Current Concept

 Ideally, master apical file, that is, the final file of prepared canal cannot be
standardized and it varies according to different cases. Nowadays, use of NiTi
rotary files with greater taper allows irrigants to reach apical third more
effectively, so it is always recommended to prevent overenlargement of minor
constriction. It can result in increased chances of preparation errors like
extrusion of irrigants, obturating material, etc. Final enlargement of the canal
depends on the following factors:
 Gauging of canal: Initial canal width guides to a large extent the master apical
file. If gauging file is 10 N, apex cannot be prepared to No. 60 MAF
 Presence or absence of periradicular pathology
 Vitality of the pulp
 Canal configuration like degree of curvature, C-shaped canal, etc.
Mechanical Objectives of Root
Canal Preparation
1. Root canal preparation should develop a continuously tapering cone
2. Making the preparation in multiple planes which introduces the concept of “flow”:
This objective preserves the natural curve of the canal.
3. Making the canal narrower apically and widest coronally: To create continuous
taper up to apical third which creates the resistance form to hold gutta-percha in the
canal.
4. Avoid transportation of the foramen: There should be gentle and minute
enlargement of the foramen while maintaining its position.
5. Keep the apical opening as small as possible.
Biologic Objectives of Root Canal
Preparation
 Procedure should be confined to the root canal space .
 All infected pulp tissue, bacteria and their by-products
should be removed from the root canal.
 Necrotic debris should not be forced periapically.
 Sufficient space for intracanal medicaments and irrigants
should be created.
5-Balanced force motion
Complications

 Instruments may separate (break) during root canal treatment, meaning a portion
of the metal file used during the procedure remains inside the tooth. The file
segment may be left behind if an acceptable level of cleaning and shaping has
already been completed and attempting to remove the segment would risk damage
to the tooth. While potentially disconcerting to the patient, having metal inside of
a tooth is relatively common, such as with metal posts, amalgam fillings, gold
crowns, and porcelain fused to metal crowns. The occurrence of file separation
depends on the narrowness, curvature, length, calcification and number of roots
on the tooth being treated. Complications resulting from incompletely cleaned
canals, due to blockage from the separated file, can be addressed with surgical
root canal treatment.
 To minimise the risk of endodontic files fracturing:
 Ensure access cavity allows straight-line introduction of files into canals
 Create a glide path before use of larger taper NiTi files
 Use rotary instruments at the manufacturer's recommended speed and torque
setting
 Adopt a single-use file policy to prevent overuse of files
 Inspecting the file thoroughly every time before inserting it inside the canal
 Using ample amounts of irrigation solutions
 Avoid use of rotary files in severely curved or dilacerated canals
Consequences of overinstrumentation

 Pain as a result of acute inflammatory response from mechanical damage to

the periapical tissue.
 In infected teeth, overinstrumentation leads to the extrusion of microbes and
infected debris which aggravate the inflammatory responses in the periapical
tissue.
 Overfilling that causes mechanical and chemical irritation of the periapical
tissue along with foreign body reaction.
 Prolonged healing time and lower success rate because of incomplete
regeneration of cementum, periodontal ligament, and alveolar bone.
Consequences of underinstrumentation

 Accumulation of infected debris

apically which impairs or prevents
healing.
 Incomplete apical seal which supports
existence of viable bacteria resulting in
poor prognosis of the treatment
Canal Transportation
 Canal transportation is defined as the “removal of
canal wall structure on the outside of the curve in the
apical half of the canal due to the tendency of files to
restore themselves to their original linear shape during
root canal preparation; may lead to ledge formation
and possible perforation”.
 Damage to the apical foramen : Original canal curvature deviation at the apical
foramen can lead to excessive over-preparation and irreversible damage. As a
consequence, the periapical tissues may be irritated by overinstrumentation, over-
preparation and risk of extruded dentine debris, irrigants or obturating materials.
 Zipping : an elliptical shape that may be formed in the apical foramen during
preparation of a curved canal when a fi le extends through the apical foramen
resulting in transportation of the outer wall”. This will often produce an “hourglass”,
“a teardrop” or “foraminal rip” at the apical foramen, which can be diffi cult to seal
and obturate.
 Elbow : Elbow formation results in a narrow portion of root canal at the point of
excessive overpreparation that occurs at the inner aspect of the curvature apically
and outer aspect of the curvature more coronally.
 Ledge : an artificial irregularity created on the surface of a root canal wall that
impedes the placement of an instrument to the apex of an otherwise patent canal”.
Ledging of curved canals is a common instrumentation error that usually occurs on
the outer aspect of the curvature due to careless manipulation and excessive cutting
 Perforation : complete penetration of a root canal wall due to excessive lateral tooth
structure removal during canal preparation; usually occurs in curved canals or
roots with surface invagination’s”. These types of perforations commonly occur in
the inner side of the curvature in the coronal and middle 1/3 rd of the canals resulting
in a communication between the root canal system and periodontal ligament in
mandibular molars at the furcal aspect known as the “danger zone”.