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Foramenal Location

Foramenal Location

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48
oral
h
ealth
 August 2004
E N D O D O N T I C S
P
redictable endodontic successdemands accurate determina-tion of,and strict adherence tothe preparation length of the rootcanal space in order to create asmall wound site and good healingconditions.
1
Each portal of exit(POE) on the root face has biolog-ic significance;this includesthe furcal canals of bifurca-tions and trifurcations,lat-eral and accessory arboriza-tions and the myriad of api-cal termini (Figs.1A-D).The ability to distinguishbetween the inner-most(physiologic/histologic fora-men) and outer-most (ana-tomic foramen) diameters of theapical terminus is essential to thecreation of the Apical ControlZone.
2
The Apical Control Zone isa mechanical alteration of theapical terminus of the root canalspace that addresses the rheologyof thermolabile filling materials,offering resistance and matrixstyle retention form against thecondensation pressures of obtu-ration (Figs.2A-C).The determination of the in-strumentation finishing level isone of the primary factors associ-ated with the resolution of anendodontic infection both clinical-ly and histologically.
3,4
The major-ity of studies postulate that opti-mal success rates occur wheninstrumentation,debridement,disinfection and obturation arecontained within the region of api-cal narrowing (bracketed by theminor apical diameter and apicalforamen.
5,6,7
In teeth/roots withapical periodontitis (AP) for exam-ple,a millimeter loss in workinglength can increase the chance of treatment failure by 14 percent.
8
The Toronto Study notedthat the highest healingrate differential (15 percent)was observed in teeth with AP that were most likelyover-instrumented resultingin transportation of contam-inated debris periapically.
9
The evidence is indisputablethat electronic root canallength measuring devicesprovide significantly more accu-rate results than radiographs
10,11
and therefore offer greater controlof the creation of the ApicalControl Zone (Fig.3).In 1942,Suzuki discoveredthat the electrical resistance (sin-
 The New Era ofForamenal Location
Kenneth S. Serota, DDS, MMSc, Jorge Vera DDS,Frederick Barnett, DMD, Yosef Nahmias, DDS, MSc 
New modes ofdebridement and disinfectionare constantly arrivingin the endodonticarmamentarium.
 
 August 2004
oral
h
ealth
49
gle current source) between aninstrument inserted into a rootcanal and an electrode attachedto the oral mucosa registered aconsistent value.In 1962,Sunadausing a direct current device witha simple circuit,demonstratedthat the consistent electrical re-sistance between the periodon-tium and the mucous membranewas 6.5 kOhms [DC Resistance].Through the 1970s,frequencymeasurements were measuredthrough the feedback of an oscil-lator loop by calibration at theperiodontal pocket of each tooth.This culminated with the effortsof Hasedgawa in 1979 with theuse of high frequency waves and aspecially coated file which couldrecord in conductive fluids.In 1983,Ushiyama introducedthe voltage gradient methodwhere a concentric bipolar elec-trode measured the current den-sity evoked in a limited area of the canal.Maximum potentialwas reached when the electrodewas at the apical constriction.The mid ’80s saw the develop-ment of a relative value of fre-quency response method wherethe apical constriction was pickedby filtering the difference be-tween two direct potentials aftera 1 kHz rectinlinear wave wasapplied to the canal space. A Third Generation electronicforamenal locator (EFL) devel-oped in the late ’80s by Kobayashiused multi-channel impedance/ ratio based technology to simul-taneously measure the imped-ance of two different frequencies,calculate the quotient of theimpedance and express it interms of the position of the elec-trode (file) in the canal.Thisformed the basis of the technolo-gy used in the ROOT ZX
 ®
(J.Morita USA,Inc.Irvine,CA)where no calibration was re-quired and a microprocessor cal-culated the impedance quotient.Fourth Generation EFL’s (Ele-ments Diagnostic,SybronEndo,Orange,CA) measure resistanceand capacitance separately ratherthan the resultant impedance value (impedance being a func-tion of resistance and capaci-tance) [Fig.4A].There can be dif-ferent combinations of values of capacitance and resistance thatprovide the same impedance (andthus the same foramenal read-ing);this can then be brokendown into the primary compo-nents and measured separatelyensuring better accuracy and lesschance for error.In addition,theElements unit uses a lookupmatrix (Fig.4B) rather than mak-ing any internal calculations.While calculations take place very quickly,they are still rela-tively much slower than simply
E N D O D O N T I C S
FIGURE 1A
—Arrows indicate mul-tiple POE’s associated with themesial-buccal and distal-buccalapices of a maxillary first molar.
FIGURES 1B & C
—The complexity of the root canal system has been graphically evidencedsince the work of Hess in the 1920s. Radical improvement in materials and techniques arenow enabling the clinician to replicate that complexity as evidenced in the cleared speci-men (1B) and the radiograph (1C).
(Courtesy of Dr. William Watson.)
FIGURE 1D
—(right) The number, shape and diameter of thephysiologic foramena at the root apex mandate the continu-ing pursuit of excellence in endodontics through increasedsophistication in materials and methods and the alliance of sci-entific innovation and clinical acumen. From Gutierrez andAguayo, OS, OM, OP June 1995.
 
looking up comparative values ina pre-calculated matrix (in therange of 10-20x slower).Thisallows the unit to “crunch”through much more data in agiven amount of time;a largersample size tends to make theresults more accurate.Figure 5demonstrates the technologicprotocol difference between 3rdand 4th generation foramenallocators.In the course of preparation of this paper,the importance of regu-lation of battery power wasassessed.The Elements Diagnosticcircuitry runs at 3.3 volts (commonfor electronics),which is internallyregulated to remain extremelyconsistent.The battery pack israted at a nominal 6 volts,7.5 voltswith a full charge and no load. As the battery pack is depleted,the voltage decreases to a pointwhere the electronics cannot con-tinue to regulate the operating voltage to such a precise valueand therefore the signals sentthrough the electrodes will not beas reliable either.The device is setto automatically shut off whenbattery voltage is a little abovethis threshold.The ROOT ZX runs on AAalkaline or lithium batteries(mixing types is to be avoided)and will shut itself off after twen-ty minutes.There is a bar graphon the face of the unit which indi-cates residual battery power.Thequestion of the accuracy of sig-nals sent through the electrode isin doubt if the battery powerlevel drops below the first threeor four bars (author’s observa-tion) [Fig.7]. A paper point measurement,foramenal detection technique hasbeen advocated by Rosenberg.
12
Itis designed to determine the pointpositional location of the apicalforamen as well as three-dimen-sional information regarding theslope of the foramen.A trial paperpoint is placed 1mm short of theEFL determined length.If thepoint is retrieved dry,it isadvanced further until fluid isnoted.The length of the segmentof the point that is dry is noted.This sequence is repeated asevidenced in Figs 6A,B& Candthe maximum length of the point
50
oral
h
ealth
 August 2004
E N D O D O N T I C S
FIGURE 2A
—The definitions of the morphologicentities comprising the regional terminus of theapex are shown diagrammatically with super-imposition of the histologic anatomy.
FIGURE 2B
—Retreatment of tooth #4.6 with K3 nickel-titanium [NiTi] files(G Pack system). The goal is identification of the histologic terminus of theroot canal space and the use of variable tapered rotary NiTi instrumen-tation to create an apical control zone and optimize the seal producedby the new generation of resin thermoplastic root canal filling materialsand sealers.
(Courtesy of Dr. Gary Glassman.)
FIGURE 2C
—Retreatment of tooth #3.6 with K3 nickel-titanium [NiTi] filesVarible Tip Varible Taper (VTVT) system. The K3 file sequence after thetwo Orifice Openers/Body Shapers is: #35/.06, #30/.04, #25/.06,#20/.04. In the majority of cases, the #25/.06 or the #20/.04 willreach the desired working length on the first pass. If not, the sequence isrepeated from the beginning.
(Courtesy of Dr. Fred Barnett.)

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