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The Working Length Controversy? Biologic Truth vs. Empirical Fiction!

by Martin Trope | Jul 7, 2016 | Faculty blog

The Working Length Controversy? Biologic Truth vs. Empirical Fiction!

The ethos of the University of Pennsylvania endodontic philosophy is guided by an unceasing

assessment of biological mandates that predicate clinical recommendations for predictably successful
treatment outcomes. None are more essential than working length determination. And yet, the
conclusions derived and recommendations made from the scientific evidence are not in concert with
many mainstream endodontic philosophies espoused by leaders in the field.

Where does the root canal space terminate and at what position should the root canal filling be located?
Numerous locations have been proposed; 1) the Minor Apical Foramen (MAF), 2) the Apical Constriction
(AC), 3) the Radiographic Apex (RA) or Radiographic Terminus (RT), 4), the Major Apical Foramen (MAF)
and 5), the Cemento-Dentinal Junction (CDJ) [Fig 1]. From a de facto standpoint, only two of these
positions do not vary from tooth to tooth; the Radiographic Apex (RA) and the Cemento-Dentinal
Junction (CDJ).

Fig 1

Fig 1
The radiographic apex as a clinically definable terminus is very appealing to techno-clinicians. Filling to
the radiographic apex has a “bullseye” aura and like “puffs”, speciously represents the optimal point for
root canal space obturation. However; from a biological approach, the bio-clinician recognizes that the
root is covered by cementum, indistinguishable from dentin in a radiograph. It is periodontal ligament
that forms cementum. Filling to the radiographic apex implies that the “fill” is into the periodontal
ligament. This is not a biologically sound terminus and is not supported by the treatment outcomes
literature which will be addressed shortly. The Cemento-Centinal Junction is the locus where the root
canal ends (dentin produced by pulp) and the periodontal ligament begins (cementum produced by
PDL). A biologic approach dictates the root canal fill should culminate at this juncture. This termination
position will almost always be short of the radiographic apex due to the cemental cap that is present at
the tip of the root. Because we cannot predictably ascertain how short we should fill, techno-clinicians
are not attracted to this philosophy.

What do treatment outcome studies suggest? Literally every study concludes that filling short of the
radiographic apex results in a greater degree of success than filling long. The classical study by Sjorgren
et al (J Endod 1990 Oct;16(10):498-504) has been duplicated many times with essentially the same
results. Filling 0-2mm short is best, long is always worse than short and the prognosis decreases as the
short fill increases above 2mm [Fig 2].

Fig 2

Fig 2
Intriguingly, the optimal filling locus for vital teeth is shown to be 0 – 2mm short of the RA, whereas, for
necrotic teeth with apical periodontitis, it is 0.5 – 1mm short of the RA. The techno-clinician incorrectly
assumes that this is because in non-vital teeth, we need to get closer to the end of the root to more
effectively eradicate microbes. In fact, the correct explanation is that in teeth with apical periodontitis,
there is usually resorption of the cementum layer around the apex making the CDJ appear closer to the
radiographic apex [Figs 3, 4].

Fig 3

Fig 3
Fig 4

Fig 4
Methods of Working Length Determination: Assessing the correct working length is a differential
diagnostic decision using a variety of methods; tactile sense, paper point, radiographs, patient response,
average root length, electronic apex locator. The Electronic Apex Locator is considered the most reliable
of these methods. Its algorithmic configuration, depending on the generation, uses impedance,
resistance, frequency and comparative databases to locate the CDJ. Research shows that if used
correctly and if the canal is patient and not blocked with dentinal debris, it does so with amazing
accuracy (> 90%). It should be apparent, that a biological approach using outcome studies as our guide,
mandates that we fill short of the radiographic apex within a range of 0.5 to 2mm, using an apex locator
followed by a pre-root filling check radiograph to assist us in determining the exact length within this
range.

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