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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 root apex’, ‘working length determination’, ‘apexifi-


cation’, ‘open apices’, ‘open apex’, ‘open apical
Kim Y-JA, Chandler NP. Determination of working length
foramina’, ‘canal length determination’, ‘immature
for teeth with wide or immature apices: a review. International
teeth’, ‘apical diameters’, ‘electronic apex locators’,
Endodontic Journal, 46, 483–491, 2013.
‘primary teeth’, ‘treatment outcome’ and ‘clinical
Practitioners face several challenges during the root outcome’ were entered. Potentially useful articles
canal treatment of teeth with wide or immature api- were chosen for a manual search of bibliography as
ces, one of which is working length determination. well as a forward search of citations. Other investi-
There is relatively little data regarding the value of gations revealed case reports and some research
radiography and electronic apex locator (EAL) use related to open apices and laboratory studies evalu-
when root formation is incomplete, and supplemen- ating EALs, radiography and tactile methods. Some
tary measurement techniques may be helpful. This involved permanent teeth of various apical diameters
review considers length determination for canals and primary teeth with and without resorption.
with wide or completely open apices in permanent There is a need to define the term ‘open apex’. Clini-
and primary teeth. The Ovid Medline, Web of Sci- cians should be aware of the benefits and limitations
ence and Scopus databases were searched individu- of all canal measuring techniques involved in man-
ally and in combinations to August 2012 using the aging this problem.
subject headings ‘working length determination’ and
Keywords: endodontics, immature apex, open
‘open apex’ and revealed only one article. Further
apex, root canal preparation, working length.
headings, ‘tooth apex’, ‘apical constriction’, ‘resorp-
tion’, ‘foramen size’, ‘mature root apex’, ‘immature Received 1 March 2012; accepted 18 October 2012

persistent periapical inflammation and postoperative


Introduction
pain (Yusuf 1982, Georgopoulou et al. 1986). The
A primary goal in root canal treatment is to reduce importance of working length control is evident in
intraradicular microorganisms to a level below that ogren et al. 1990, Ng et al.
epidemiological studies (Sj€
necessary to induce or sustain apical periodontitis 2008), and histological evidence confirms that opti-
(Siqueira & R^oßcas 2008). An essential prerequisite is mal healing is obtained when there is minimal con-
establishment of correct working length during root tact between canal filling material and periapical
canal preparation, as failure to do so may result in tissue (Ricucci & Langeland 1998).
accidental extrusion of irrigant, dressing or filling and 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
Correspondence: Nicholas Chandler, School of Dentistry, Uni-
versity of Otago, PO Box 647, Dunedin 9054, New Zealand
primary teeth due to eruption of the permanent suc-
(Tel.: 0064 3 479 7124; fax: 0064 3 479 5079; e-mail: nick. cessor (Gutmann & Heaton 1981). It may also be
chandler@otago.ac.nz). iatrogenic, the result of overinstrumentation or root

© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd 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 1991, Mente et al. 2009). There is therefore a need
apex is often used to describe an exceptionally wide for clinical guidelines for working length determina-
apical foramen, in which preparation of an apical tion in teeth with open apices.
‘stop’ is difficult, if not impossible to achieve. The defi-
nition of open apex varies according to authors and is
Working length determination for open
reflected by the minimum ISO size used to describe it:
apices
ISO 40 (Mente et al. 2009), ISO 45 (Van Hassel &
Natkin 1970), ISO 60 (Sarris et al. 2008, ElAyouti The European Society of Endodontology (2006) rec-
et al. 2009), ISO 80 (Friend 1966, Moore et al. 2011) ommends the use of an electronic apex locator (EAL)
or ISO 100 (Andreasen & Andreasen 2000). With followed by confirmation of canal length with an
these sizes, a root canal file can be passed freely undistorted radiograph during root canal treatment. If
through the apical foramen, and there may be radio- the instrument in the canal appears to be more than
graphic evidence of open apex (Moore et al. 2011). 3 mm from the radiographic apex, the working
Although the exact landmark for termination of length needs to be adjusted. Although radiography is
root canal treatment remains controversial, there is the main method of selecting working lengths during
general agreement that the apical constriction the treatment of teeth with open apices, case reports
is appropriate (European Society of Endodontology and clinical trials have reported variations in tech-
2006). The apical constriction is considered to be the nique. Numerous researchers recommend Ingle’s
narrowest region of the apical portion of the root (1957) method, the radiographic estimation of the
canal system (Dummer et al. 1984). However, it is working length 1–2 mm short of the radiographic
not always present in cases of root resorption associ- apex determined from a pre-operative radiograph or
ated with pulp and periapical pathosis, or in teeth from tactile sense (Ingle 1957, Friend 1966, Duell
with open apices (Friend 1967, Dummer et al. 1984, 1973, Gilbert 1983, Dummer et al. 1984), whilst Van
Laux et al. 2000). Most studies that have evaluated Hassel & Natkin (1970) instrumented to the radio-
the anatomy and diameters of apical constrictions are graphic apex during treatment of immature perma-
confined to the fully developed apices of permanent nent teeth with open apices. Several reports have
teeth, with pathological condition unstated and with mentioned the use of radiographs for length determi-
limited age groups or sample size (Kuttler 1955, nation but did not elaborate further (Frank 1966,
Dummer et al. 1984). There is little information Sarris et al. 2008, Yassen et al. 2012). Whitworth &
regarding the anatomy of incomplete apices. In a Nunn (2001) suggested preparing the canals 2–3 mm
radiographic analysis of the immature permanent short of an estimated working length obtained from
teeth of 7.5–15-year-olds, Friend (1966) described an undistorted pre-operative periapical radiograph.
three types of open apices: divergent, parallel and Moore et al. (2011) reported using both conventional
tapering. He stated that as root development in the radiographs and an EAL. Omitting local anaesthesia
labio-lingual plane lags behind that in a mesio-distal has also been suggested, as any sensitivity or haemor-
direction, a parallel apex seen on a radiograph would rhage may indicate the need to adjust file length
appear more divergent if the image could be taken (Friend 1966, Duell 1973).
proximally. He concluded that it is impossible to thor- Despite radiographs being the key method of deter-
oughly instrument the apical portion of these canals mining working lengths, there are several factors
(Friend 1967). This is supported by others, who sug- influencing their accuracy (Andreasen & Andreasen
gest difficulties in chemomechanical preparation and 1985, Tidmarsh 1987, Mentes & Gencoglu 2002).
filling of such canals may lead to residual infection Paralleling techniques produce more reliable tooth
(Pinar Erdem & Sepet 2008). Steiner et al. (1968) length determination than the bisecting angle method
went further, suggesting that instrumentation of the (Forsberg 1987). However, in a laboratory study by
apical portion of these canals must be avoided to pre- ElAyouti et al. (2001), the authors found that radio-
vent thinning of their fragile dentinal walls. Approxi- graphic lengths 0–2 mm short of the radiographic
mate working lengths determined radiographically apex led to file positions beyond the apical foramen in
would suffice. More reliance might be placed in the 22–51% of cases in molars and pre-molars, but not in
use of calcium hydroxide dressings to disinfect the anterior teeth. Combining the use of EALs with radio-
canal and prevent the consequences of overzealous graphs was recommended in a subsequent paper to
instrumentation of thin dentine walls (Sj€ ogren et al. avoid over-instrumentation (ElAyouti et al. 2002). In

484 International Endodontic Journal, 46, 483–491, 2013 © 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 et al. 2006b) and > size 90 (ElAyouti et al. 2005,
in an up to 7.58% over-estimation of the actual Herrera et al. 2011). Some differences may be due to
canal length (Mentes & Gencoglu 2002); thus, with the settings in which the experiments took place and
radiographs, there is the potential for unintentional the EAL used. Additionally, caution is necessary when
over-instrumentation. interpreting laboratory studies as there may be no
Anatomical noise, such as the superimposition of reason given for the extraction of the teeth used or
the maxillary sinus and zygomatic arch, can influence any apical disease present. The presence or type of
the accuracy of working length, especially if the tissue in the canal may influence the accuracy of the
bisecting angle technique is used (Tamse et al. 1980, Root ZX (J. Morita Mfg. Corp., Kyoto, Japan). In a
ElAyouti et al. 2001). In addition, variables, such as clinical study, Dunlap et al. (1998) found two read-
the shape and orientation of the apex in relation to ings in their necrotic group were 1.5 mm beyond the
the X-ray beam, observer variability, film speed, and apical constriction. Such findings might be due to api-
viewing conditions, such as the presence of extrane- cal resorption in the extracted teeth (Goldberg et al.
ous light, can all influence the accuracy of radio- 2002).
graphic working length determination (Olson et al. A number of laboratory studies have reported that
1991, Stein & Corcoran 1992, Sheaffer et al. 2003, irrigants do not affect the accuracy of modern EALs
Orafi et al. 2010). As Dummer et al. (1984) sug- (Vajrabhaya & Tepmongkol 1997, Kaufman et al.
gested, a combination of methods increases the accu- 2002, Meares & Steiman 2002). However, the ability
racy of length determination. 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
Use of electronic apex locators
apical foramen. The Root ZX was developed in 1994
With the development of EALs, assessment of working to help reduce electro-conductivity within the canal
length has become more predictable, reducing some associated with electrolytes or vital pulp tissue (Ko-
shortcomings of radiographs and the number taken bayashi & Suda 1994). Nevertheless, blood in the
during treatment (Brunton et al. 2002, Chandler & canal appears to adversely affect its readings, espe-
Koshy 2002). Use of an EAL may prevent uninten- cially when smaller files were used in canal sizes 40–
tional over-instrumentation (Stein & Corcoran 1992, 80 (Ebrahim et al. 2006b). On the other hand, in the
ElAyouti et al. 2001, Ravanshad et al. 2010). Despite presence of 6% sodium hypochlorite (NaOCl), the
having an accuracy of 80–90% in most root canals Root ZX was not significantly influenced by smaller
(Gordon & Chandler 2004), their performance can be files, irrespective of canal sizes from 40 to 80. When
limited by multiple factors: presence of a nearby a size 10 file was used in canals prepared to size 80,
metallic restoration or vital tissue, the type of any the largest discrepancies were 0.19 and 1.11 mm in
electrolytes in the canals, the diameter of the apical groups irrigated with NaOCl and human blood respec-
foramen, an absence/presence of apical constriction tively. In other words, without blood and possibly
and the size of file in use (Berman & Fleischman serum or pus, relatively reliable working lengths can
1984, Goldberg et al. 2002, Lee et al. 2002, Fan et al. be obtained with the use of the Root ZX in canals

2006, Ozsezer et al. 2007). Berman & Fleischman containing NaOCl prepared to size 80 regardless of
(1984) recognized the limitations of first generation the dimensions of the measuring file. By contrast, Fan
devices in teeth with immature apices in their in vitro et al. (2006) using glass tubes of different diameters
study. This was confirmed in a laboratory study by to mimic root canals found 2.5% NaOCl had a signifi-
H€ulsmann & Pieper (1989) using a second generation cant impact on the accuracy of the Root ZX, whilst
EAL (Exact-a-pex, Ellman, New York, NY, USA). They the Neosono Ultima EZ (Amadent, Cherry Hill, NJ,
observed that all EAL readings were short of actual USA) remained unaffected. Interestingly, three-third-
working length in cases of immature permanent teeth generation EALs showed substantial variations in the
with apical foramina exceeding size 50. Although differences between the real lengths and the measured
third-generation EALs were designed to overcome lengths when the tube diameters were 0.80–1.00 mm.
some of these limitations (Fouad et al. 1993), the api- In the presence of 2.5% NaOCl, the measurement errors
cal foramina diameters above which canal measure- displayed were 5.65  1.84 mm, 0.83  0.36 mm,
ments became unreliable vary: > size 60 (Ebrahim 0.4  0.13 mm, respectively, for TriAuto ZX (J. Morita),
et al. 2006a, Herrera et al. 2007), > size 80 (Ebrahim ProPex (Dentsply Maillefer, Ballaigues, Switzerland) and

© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd 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 situations, there is often a lack of ideal circumstances
such findings as the impedance ratio measurements may for precise measurement (Beltrame et al. 2011).
be influenced by conducting media.
A snug-fitting file is recommended to measure
Alternative measurement of working
working lengths especially in the presence of blood
length for open apices
(Stein et al. 1990, Ebrahim et al. 2006b). However,
several laboratory studies show that file sizes from 10 Several studies have investigated other methods of
upwards did not make a difference for apical constric- working length measurement for teeth with open api-
tion diameters up to size 60 using the Root ZX (Saito ces. Baggett et al. (1996) evaluated a tactile tech-
& Yamashita 1990, Nguyen et al. 1996, Herrera et al. nique using paper points and claimed it to be
2007). The Root ZX proved unreliable with a size comparable to radiography and unaffected by the size
100 apical constriction, with mean measurement of the apex or the presence of periapical pathology.
errors ranging from 0 to 1.03 mm, and it was not The technique involved using a size 30 paper point
clear whether better fitting files (size 100) gave more placed in the canal and advanced until resistance was
reliable readings (Herrera et al. 2007). Ebrahim et al. felt. The authors found that this method was accurate
(2006b) noted that beyond size 80, there was a mea- to within 1 mm of the radiographic diagnostic length
surement error of 2.24 and 0.88 mm with the use of 95% of the time and concluded that a working length
size 10 and 80 K-files, respectively, using the Root ZX. radiograph was unnecessary when this method was
The Apit 7 (Osada Electric Co, Tokyo, Japan), on the employed. A shortcoming of the technique is that if
other hand, gave the largest measurement errors of periapical soft tissues extend into the canal, underesti-
2.84 and 1.61 mm (Ebrahim et al. 2006b). The Root mation of the working length could result. Up to
ZX performed significantly better than the other three 3 mm of soft tissue was present in two of 35 cases
EALs tested in this study. Nevertheless, the measure- studied (Baggett et al. 1996). Additionally, there is
ment error increased when apical size 150 was evalu- the potential for overfill when the level of the apical
ated, with the Root ZX showing errors of 5.12 and terminus, affected by pathological resorption, is
2.14 mm, respectively. A recent laboratory study by uneven. This may not be evident radiographically,
Herrera et al. (2011) using the Root ZX revealed that especially if the shorter aspect is in the bucco-lingual
regardless of file size, it was accurate for an apical size direction. To overcome this problem, ElAyouti et al.
of 60, whereas better fitting files (minimum 45) should (2009) proposed a tactile method involving the use of
be used for apical sizes from 70 and 80. All in all, a size 25 K-file bent at the tip, with its orientation
within a tolerance of 1 mm, the accuracy was in the marked with a silicone ring. The file was bent to facil-
range of 95–99% for all diameters of apical foramina. itate ease of use. This method may be restricted to rel-
Nevertheless, above size 90, this EAL was inaccurate atively straight canal curvatures (<10 degrees).
(Herrera et al. 2011). Clinical trials are needed to further assess this
It appears that not all EALs are able to prevent method, especially in curved canals.
over-instrumentation (ElAyouti et al. 2005). These Although never proven accurate for open apices, the
workers compared three instruments, the Root ZX, paper point technique described by Rosenberg (2003)
Raypex®4 (VDW GmbH, Munich, Germany) and the to supplement initial EAL readings could be considered
Apex Pointer (Micro Mega, Besancßon, France), in for the working length determination of open apices in
resected root-ends with sizes of apical terminus vary- relatively straight canals (  10 degrees). The tech-
ing from 50 to 90 and using a size 15 measuring file. nique is described as follows: given that the canal is
It was found that none of the readings with the Root dry, an initial paper point is placed 0.5 mm short of the
ZX resulted in overestimation of the working length, EAL indicated length. If the point comes out dry, it is
whilst 4% of readings with the Raypex®4 and the advanced apically in the canal in small increments
Apex Pointer did. Although there were statistically (0.25 mm) under magnification until some fluid is
significant differences between the readings at apical picked up. Another paper point is used just short of this
terminus sizes 50–60 and 70–90, with the means point, and the working length is then the maximum
ranging from 0.27 to 0.38 mm between the two length that a point can be placed into the canal and
groups, it appears that the difference is clinically remains dry. Rosenberg (2003) cautioned that the
acceptable. Clearly, the results from laboratory studies paper point should only remain in brief contact before
need to be interpreted with caution, as in clinical any capillary action has taken place. A study using

486 International Endodontic Journal, 46, 483–491, 2013 © 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 between the apical limit of MTA and success. Subse-
method using micro-computed tomography (Marcos- quently, Moore et al. (2011), who treated 22 incisors
Arenal et al. 2009). Following paper point assessment and had an average follow-up period of 2 years,
and tooth extraction, files were positioned and imaged, found a strong association between MTA plug posi-
and the method found to be reliable in straight canals. tion and treatment outcome. The ideal MTA position
It was 87% accurate to within  0.5 mm of the apical was not defined but was reported in 63.6% of cases,
foramen, with high repeatability. However, prerequi- whilst 9.1% were underfilled and 27.3% were over-
sites included a dry canal and wet periapical tissue, filled. A nondivergent apical shape facilitated ideal
which were not obtainable in eight of the 84 canals in positioning of the plug, and these teeth were associ-
the study. 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-
Working lengths and outcomes
gent canals. The potential role of the apical limit of
Epidemiological evidence suggests that a favourable filling material in the long-term outcome of canals
outcome is associated with a root filling placed within with open apices with contemporary materials war-
0–2 mm of the radiographic apex, with overfilling or rants further investigations.
underfilling adversely affecting outcome if infection is
present (Sj€ ogren et al. 1990, Negishi et al. 2005).
Primary teeth
According to Negishi et al. (2005), teeth that featured
apical periodontitis where the apical constriction The apical extent of the root canal system of primary
could not be determined by an EAL had a five times teeth is difficult to determine (Goerig & Camp 1983,
greater risk of failure. In this group, the distance from Rimondini & Baroni 1995). Physiological resorption
the apex varied from less than 2 mm to more than may be complicated by pulp and periodontal inflam-
2 mm, with the mean distance 3.95 mm from the mation, and it is essential to minimize potential
radiographic apex. The largest master apical file used damage to the permanent successors (Holan & Fuks
was greater than size 40. It seems that regardless of 1993, Coll & Sadrian 1996). Extruded root canal
the size of the apical canal, the presence of apical fillings have a lower success rate than if the root fill-
periodontitis pre-operatively and inability to control ing is short or to the apex in primary teeth (Coll &
infection to the full working length play significant Sadrian 1996). There is general consensus that root
roles in the treatment outcome. As contemporary root canal treatment is contraindicated in primary teeth
filling materials are either biocompatible or induce displaying root resorption of more than one-third of
temporary cytotoxicity prior to setting, it is unlikely the root.
that failures would occur as a result of overfilling Several clinical studies have evaluated the accuracy
without infection (Bystr€ om et al. 1987, Sj€ogren et al. of third-generation EALs in primary teeth with and
1997, Shabahang et al. 1999, Felippe et al. 2005). without resorption, demonstrating the efficacy of this
Infected, overfilled root canals are often associated method (Kielbassa et al. 2003, Beltrame et al. 2011,
with poor marginal adaptation and apical seal, Odabas et al. 2011). According to Kielbassa et al.
which may allow nutrients from the periapical tissue (2003), using a group of primary teeth (34 molars,
to reach remaining bacteria to sustain infection. 37 incisors) with and without resorption, the Root ZX
Extruded infected dentinal debris also leads to the per- was accurate to within 1 mm in 64% of cases. No
petuation of apical periodontitis (Sarris et al. 2008). influence of type of tooth or presence or absence of
Schaeffer et al. (2005) in their meta-analysis evaluat- root resorption was noted. This finding was in agree-
ing optimal obturation length concluded that it ment with the clinical study by Odabas et al. (2011),
should be 0–1 mm short of the radiographic apex, as who concluded that the Root ZX had high accuracy
overfill may decrease the prognosis for repair. (86.35–95.82% within 1 mm) irrespective of presence
Clinical studies evaluating the outcome of healing or absence of root resorption, and a study by Beltrame
in teeth with open apices filled with MTA show et al. (2011) who found the Root ZX to be highly pre-
favourable results (Simon et al. 2007, Holden et al. dictable in primary molars with varying levels of
2008, Witherspoon et al. 2008, Moore et al. 2011). resorption. Interestingly, in up to 7.7% of the teeth, the
Sarris et al. (2008), who followed up 17 treated inci- Root ZX had overestimated the working length by more
sors for up to a year on average, found no association than 1 mm (Beltrame et al. 2011).

© 2012 International Endodontic Journal. Published by Blackwell Publishing Ltd 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 reliable when there is a degree of taper in the apical
of EALs in primary teeth with root resorption (Mente canal shape (Goldberg et al. 2002, Angwaravong &
et al. 2002, Ghaemmaghami et al. 2008, Leonardo Panitvisai 2009, Odabas et al. 2011). Although stud-
et al. 2008, Tosun et al. 2008, Bolan & Rocha 2010, ies support the use of EALs in primary teeth display-
Mello-Moura et al. 2010, Nelson-Filho et al. 2010). ing physiological resorption, the relation of the extent
Tosun et al. (2008) compared the performance of the of the apical root resorption to the accuracy of EALs
Root ZX and the Tri Auto ZX with file size 15 and remains to be explored. Furthermore, potential prob-
found their respective accuracy to be 98.2% and lems exist when EALs are used in cases where the
100%, which, being in a laboratory setting, are apical dimension is wider than its more coronal
expected to be higher than the results from clinical aspect, precluding contact of the file with the sur-
studies (Kielbassa et al. 2003, Beltrame et al. 2011). rounding apical walls of the root canal (H€ ulsmann &
The presence of root resorption had more influence Pieper 1989). It appears that combining radiography
on the accuracy of the Tri Auto ZX than the Root ZX, and the EAL when determining working lengths of
whilst in the study of Bolan & Rocha (2010), there primary teeth displaying resorption should give a
was no significant difference between two EALs tested, more predictable result.
the Root ZX and Apex Pointer, despite the presence
or absence of resorption. In a laboratory study in Conclusion
extracted primary teeth displaying root resorption of
up to one-third of root length Angwaravong & Pani- There is a need for a clear definition of what com-
tvisai (2009) confirmed the accuracy of the Root ZX, prises an ‘open’ apex, and more research is necessary
96.7% within 0.5 mm when files 15–40 were used. on how best to image the very fine detail of root api-
On the other hand, Bodur et al. (2008) found neither ces. Clinically, owing to their limitations, the use of
of the EALs they tested, the Root ZX and Endex EALs and radiographs should be supplemented with
(Osada Electric Co.) were reliable. There was no statis- other methods, especially when treating very wide
tically significant difference between primary teeth apical terminations. No long-term studies have been
showing resorption and those without. The authors carried out to evaluate supplementary techniques. In
recommended that adjunctive methods should supple- addition, further studies are needed to show the accu-
ment the use of EALs. racy of working length methods in cases of apical
Laboratory studies have compared the ability of resorption.
conventional and digital radiography and EALs in
determining working lengths in primary teeth with or References
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