Working Length Determination, Endodontic Radiology

Dr Nawaf Al-Hazaimeh

WORKING LENGTH DETERMINATION

The working length is defined as the distance from a predetermined coronal reference point (usually the incisal edge in anterior teeth and a cusp tip in posterior teeth) to the point that the cleaning and shaping, and obturation should terminate. The reference point must be stable so fracture does not occur between visits.

 Optimal length 1-2mm short of the apex.

Apical foramen Anatomical apex Apical constriction

 A, The apical foramina (small arrows) do not correspond to the true anatomic apex (large arrows). B, In most situations the apical terminus or seat of the preparation will vary from the apical foramen and radiographic apex

 Apical Constriction The presence of an apical constriction is unpredictable. Frequently there is no apical constriction. It has been proposed that the cementodentinal junction forms the apical constriction; however, this concept is incorrect. In fact, the junction is difficult to determine clinically with accuracy, and the intracanal extent of cementum is variable. If an apical constriction is present, it is not visible on a radiograph and usually is not detectable with tactile sense using a file, even by the most skilled practitioner.

 Reference point

Before access an estimated working length is calculated by measuring the total length of the tooth on the diagnostic parallel radiograph or digital image.

 2.0 millimeters are subtracted to account for the foramen distance (1.0 mm) and radiographic image distortion /magnification (1.0 mm). This provides a safety factor so instruments are not placed beyond the apex. After access preparation, a small file is used to explore the canal and establish patency to the estimated working length. The largest file to bind is then inserted to this estimated length

 Millimeter markings on the file shaft or rubber stops on the instrument shaft are used for length control. A sterile millimeter ruler or measuring device can be used to adjust the stops on the file

 To obtain an accurate measurement, the minimum size should be a No. 20. With files smaller than No. 20, it is difficult to interpret the location of the file tip on the working length film or digital image. It is imperative that the rubber dam be left in place during working length determination to ensure an aseptic environment and to protect the patient from swallowing or aspirating instruments.

 With the modified paralleling technique, the film is positioned by using a film holder parallel to the long axis of the tooth. The cone is then positioned so the central beam will strike the film at a 90-degree angle Other clinical factors should be considered in establishing the corrected working length. These include tactile sensation, the patients response, and hemorrhage.

Corrected working length

WL distance from the apex is Determined when radiographically there is No bone or root resorption (A)
1 mm from apex

Bone but no root resorption (B)

1.5 mm from apex

Bone and root resorption (C )

2 mm from apex

 When the correction is greater than 3.0 mm, it is advisable to make a second working length radiograph with the file placed at the adjusted length.

 An apex locator is very helpful in patients with structures or objects that obstruct visualization of the apex, patients that have a gag reflex and cannot tolerate films, and patients with medical problems that prohibit the holding of a film or sensor. The use of apex locators and electric pulp testers in patients with cardiac pacemakers has been questioned.

IMPORTANCE OF RADIOGRAPHY IN ENDODONTICS

Radiographs perform essential functions in three areas. However, they have limitations that require special approaches. A single radiograph is but a 2-dimensional shadow of a 3-dimensional object. For maximum information, the third dimension must be visualized and interpreted. The three general areas of application are diagnosis, treatment, and recall; each requires its own special approach.

 Diagnosis
Root and pulp anatomy Identifying Pathosis Characterizing normal structures.

Treatment
Determinig working length Moving superimposed structure Locating canals Evaluating obturation

Recall
Identifying new pathosis Evaluating Healing

 A, Parallel preoperative radiograph. B, The mesial working length film is made correctly. The apices and file tips are clearly visible. Note the mesiolingual canal (arrow).

Diagnosis
The facial projection of this premolar gives some limited information about pulp/root morphology. Fast break (small arrow) usually indicates canal bifurcation. B, The same premolar from the proximal view. The presence of two definitive canals, each in its own root bulge, is confirmed.

 when two objects and the film are in a fixed position and the radiation source (cone) is moved, images of both objects move in the opposite direction. The facial (buccal) object shifts farthest away; the lingual object shifts less. The resulting radiograph shows a lingual object that moved relatively in the same direction as the cone and a buccal object that moved in the opposite direction. This principle is the origin of the acronym SLOB (same lingual, opposite buccal)

The SLOB rule

The film is positioned parallel to the plane of the arch. The cone has the central ray (arrow) directed toward the film at right angles. This is the basic cone-film relationship used for horizontal or vertical angulations. B, There is a clear outline of the first molar but limited information about superimposed structures (canals that lie in the buccolingual plane). The arrow points to a periodontal ligament space adjacent to a superimposed root bulge, not to a second canal

A, The horizontal angulation of the cone is 20-degrees mesial from the parallel, right-angle position (mesial projection). B, The resultant radiograph demonstrates the morphologic features of the root or canal in the third dimension. For example, two canals are now visible in the distal root of the first molar

SLOB Rule

Central (x-ray) beam passing directly through a root containing two canals will superimpose the canals on the film. When the cone is shifted to the mesial or distal aspect, the lingual object will move in the same direction as the cone; the buccal object will move in the opposite direction (SLOB rule).

Determination of Working Length

A, Mesial projection gives limited information about morphologic features and relationship of four canals. B, Correct distal projection for mandibular molars opens up roots. Mesial canals are easily visualized for their entire length. The distal canal is a single wide canal because instruments are close and parallel

 Facial
Maxillary anterior teeth rarely have more than a single root and a single canal, thus only a facial (straight-on) projection is required. This is also true for maxillary molars unless a second mesiobuccal (mesiolingual) canal is detected and negotiated during access. The straight facial projection provides maximum resolution and clarity (which is difficult at best with maxillary molars).

 Mesial The mesial projection is indicated for maxillary and mandibular premolars and for mandibular canine teeth. A mesial projection is used for maxillary molars with a mesiolingual canal.

 Distal The distal projection is used for mandibular incisors and mandibular molars. The distal is preferred to the mesial projection for mandibular molars because of the relative position of the canals. Generally, the distal angle more effectively opens up the mesial root.

Separation of the mesiobuccal and mesiolingual canals achieved by varying the horizontal angle. With maxillary molars maximum separation occurs with a mesial cone angulation because of the mesial location of the mesiolingual canal in relation to the mesiobuccal canal.

Separation of the mesiobuccal and the mesiolingual canals achieved by varying the horizontal angle. With mandibular molars, maximum separation occurs with a distal orientation because of the mesial location of the mesiobuccal canal in relation to the mesiolingual canal.