Clinical techniques

Annals and Essences of Dentistry

A TACTILE METHOD FOR CANAL LENGTH DETERMINATION IN TEETH WITH OPEN APICES- A CASE REPORT.
*Anuraag Gurtu **Anurag Singhal ***Payal Singhal
*Reader, **Professor and Head,***Postgraduate Student- Department of Conservative Dentistry and Endodontics, Instititute Of Dental Sciences, Bareilly, India.

ABSTRACT

The term open apex is used to indicate the presence of an exceptionally wide root canal at the apex. Open apices occurs in immature teeth when root development ceases as a result of pulp necrosis. Trauma and caries are regarded as the main cause of open apices in immature anterior teeth. Successful root canal treatment occurs when overinstrumentation and overfilling are avoided and filling materials confined to the limits of the canal. Hence, accurate working length is essential for optimal healing. Open apices pose many difficulties to contemporary methods of canal length determination. A case report presents a consistent tactile method for working length determination in teeth with open apices.
KEYWORDS:- Open apex, Trauma, Working length. INTRODUCTION The term open apex is used to indicate the presence of an exceptionally wide root canal at the apex. Trauma and caries is regarded as the main cause of open apices in immature anterior teeth. In fully developed teeth causes of open apices include extensive apical resorption, root- end resection and 1 over instrumentation . The short thin- walled roots of open apices increases the risk of fracture and have an unfavourable crown- root ratio. The extensive apical resorption, facilitated by the thin- walled dentine and long standing infection, impedes accurate canal length determination. Successful root canal treatment occurs when overinstrumentation and overfilling are avoided and filling materials confined to the limits of the canal. Accordingly, accurate working length determination is essential in achieving optimal healing. Open apices pose many difficulties to contemporary 1 methods of canal length determination . The aim of the present paper is to present a consistent tactile method for working length determination in teeth with open apices.

palpation in the labial vestibule and exhibited grade I mobility. The palatal and labial soft tissues surrounding the anterior teeth did not exhibit any swelling or sinus tract. The teeth were not luxated and no root fractures were detected. The radiograph showed the left central incisor having a open apex. (Fig 2).

Tactile method
For this, size 25 K- file was used. The file was bent at the tip (0.5- 1mm) to a 90 angle . A small silicon ring was attached to the shaft of the file (Fig. 3). A black mark on the silicon ring indicated the direction of the bent tip. The Correct Working Length (CWL) was defined to be at the level of the shortest dentinal wall as at this level the root canal is surrounded by dentine. The CWL was measured using the bent file with the silicon stopper was adjusted to a coronal reference point. The bent tip was placed against a dentinal wall in the root canal and moved apically until it engaged the edge of dentinal wall at the apex. The silicon ring was adjusted to the coronal reference point and the file was then rotated to disengage the bent tip. The same procedure was repeated for all the dentinal walls i.e., Mesial, Distal, Labial and Palatal. The shortest length detected 1 represent TACTILE WORKING LENGTH (TWL) . The working length was measured from the bent tip to the silicon ring (Fig.4).

Case report
A 28-yr-old woman suffered painful symptoms in her upper Central incisors and required evaluation and treatment. She had a history of having suffered a traumatic incident few years back. The upper central incisors on clinical examination were discolored (Fig. 1). The tooth was tender to Vol. - II Issue 3 July Sept. 2010

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Clinical techniques

Annals and Essences of Dentistry

Fig. 1. Discolored Central Incisors Fig. 2. Bent K- file Fig.3. Immature root of central incisor Left

Mesial Wall

Distal Wall

Labial Wall

Palatal Wall

Fig.4. Tactile(TWL) Working Length

Fig.5.Post obturation Radiograph- Right central incisor

Fig.6. Bone graft and MTA placed in left central incisor

Fig.7.Thermo plasticized Gutta percha obturation

Fig.8. Follow-up radiograph after 6 weeks

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Issue 3 July Sept. 2010

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Clinical techniques
The canal was biomechanically cleaned and irrigated by using sodium hypochlorite and normal saline. Then the canal was dried by using paper points and calcium hydroxide dressing was given for one week to disinfect the canal. In the meantime, conventional Root canal treatment was done in right Central Incisors (Fig. 5).For left central incisors after one week tooth was asymptomatic, Bone graft was mixed with PRP and was placed into the periapical defect by using hand plugger (Fig. 6). Then, MTA was chosen to form the apical matrix. The CWL helped to place the MTA at correct location and avoided any extrusion of MTA. After placement of MTA moist cotton pellet was placed in to the canal to fasten the setting of MTA. On the subsequent appointment obturation was done by using thermoplasticized GP and AH-26 root canal 2,3 sealer .(Fig. 7).

Annals and Essences of Dentistry

within 1 mm from the radiographic apex considered accurate. were

CONCLUSION Hence, we can conclude that the determination of an appropriate working length is a very essential step for the predictable, successful outcome of the endodontic treatment. Teeth with open apices present difficulty in estimation of working length by normally accurate, efficacious, conventional methods. Tactile method offer an less explored accurate alternative to contemporary methods of working length determination.

References
1. A. EIAyouti etal 2009. A Tactile method for canal length determination in teeth with open apices. International Endodontic Journal, 42, 1090- 1095. Kerezoudis NP etal 1999. A method of adapting gutta-percha master cones for obturation of open apex cases using heat. International Endodontic Journal 32, 53-60. Morse DR etal 1990. Apexification: Review of the literature. Quintessance International 21, 589- 98. A. EIAyouti etal 2006. A simple mounting model for consistent determination of the accuracy and repeatability of apex locators. International Endodontic Journal 39, 108- 12. Goldberg F etal 2002. In vitro measurement accuracy of an apex locator in teeth with simulated apical root resorption. Journal of Endodontics 28, 461-3.

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Discussion
The accuracy of Tactile Method , calculated in teeth with open apices was high (97.7%). The Tactile Method is not feasible in curved canals or in teeth with an apical size smaller than 80, but these clinical situations are uncommon for teeth with open apices. Apex locators have been shown to be highly accurate in locating the apical foramen and 4 constriction . Unfortunately, in open apices they give incorrect measurements i.e., the electronic working length is shorter than the actual canal length. Hulsmann & Pieper found that apex locators did not function in teeth with open apices with a 5 accuracy rate of only 62.7% . Radiographic Methods may lead to overestimation of the canal length. The main reason is the fact that the apical foramen is frequently (92%) located short of the apex and the length of the measuring file appears radiographically shorter than its actual length. In teeth with open apices the radiographic interpretation of canal length is even more difficult due to the altered apical anatomy and the missing periodontal ligament space at the apex The paper point techniques may deliver accurate measurements provided that the periapical tissues exist at the same level of canal terminus and that moisture control is possible within the canal as well as from the periapical tissues. Baggett et al calculated an accuracy of 95% for the paper point technique when all measurements Vol. - II Issue 3 July Sept. 2010
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Corresponding Author
Corresponding Author Dr. payal singhal
H no : 208/2 prem nagar near divya prakash press Bareilly Phone No: 9897647615 e mail: kunal.singhal@yahoo.com

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