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Clinical

The paper point technique: Part one


David B Rosenberg DDS illustrates an approach for finding
the working length that can be used to improve
the quality and consistency of endodontic procedures

Some ideas are accepted and pursued more readily than


others. As an example, the concept of man flying was not taken
seriously until modern times. From Da Vinci’s conceptual
illustrations to the Wright brothers’ accomplishments centuries
elapsed. Significant technological advances have produced both
the space shuttle and the hang glider. It has taken longer to get
Da Vinci’s hang glider in the air than a rocket. Today’s hang
glider works because it has borrowed and modified advanced
technology.
Scientific and technological advances in endodontics have
allowed the use of simple devices in sophisticated ways. Today
we can routinely use paper points to determine the length of
a canal (Buchanan LS, 1991). This is possible because of
modern instrumentation techniques and nickel titanium files of
greater taper.
While the paper point may seem like Da Vinci’s hang glider
when compared to digital radiography or an apex locater, it gives
more accurate information about canal length and shape than any
other technique available (Figures 1-4). The accuracy of paper
point measurements also allows for the elimination of working
films while improving the technical quality of the endodontics
performed (Figure 5).
Achieving technical endodontic excellence is largely depend-
ent upon knowing two variables:
1. At what length the cavosurface of the canal is found
2. The minimum apical foramen diameter (MAFD) at that length.
Knowing these variables allows the dentist to have excellent
control of the root canal system. The length to the cavosurface
of the canal can be determined to within 0.25mm accuracy using
the paper point technique, which does not require measurement
radiographs.
Radiographs and apex locators are used to estimate the work-
ing length of canals. When estimates of length and MAFD are
made, the quality of endodontic procedures will inherently vary. Figure 1: This radiograph shows a central incisor that has had an apicoectomy.
There is a retrograde filling that has been placed into the root but not the
Accurate knowledge of canal length and MAFD can be used to
canal
produce consistent high quality results. This two-part article will
attempt to illustrate an approach that can be used to improve the comes without working films, some definitions are needed.
quality and consistency of endodontic procedures Let the cavosurface of the canal be defined as a plane that
bisects the root at a point comprised of the most coronal position
Definitions of the apical foramen where the internal surface of the canal
meets the external surface of the root. This point is now
Before discussing a more accurate way to ascertain the variables considered to be at the most apical portion of the canal and
required for optimum control of endodontic procedures and out- no other points on the plane are more coronal to it (Figure 6). It
is not important to know if this cavosurface plane bisects
cementum or dentin, or both. The importance is in knowing
Dr Rosenberg has a full-time practice limited to endodontics in where the demarcation of internal canal and external root exists
Vero Beach, Florida, USA. He is a diplomate of the American (Figures 7 and 8).
Board of Endodontics, and a Fellow of the American and
Endodontics is successful when an environment is created that
International Colleges of Dentists. Dr Rosenberg offers hands-on
will allow the immune system to function to repair injury. We
courses in Florida that attracts dentists internationally. He can be
only need to treat what is inside the canal. All points that are
contacted by email at DROSENB143@aol.com
located apical to the cavosurface of the canal can be considered

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Figure 2: The paper point used to determine the location of the cavosurface of Figure 3: The information gathered from the paper point can be used to
the canal also reveals the angle of the surgically placed bevel and its customize the gutta percha cone used for obturation
orientation

to be in contact with the immune system. All points coronal to


the plane of the cavosurface are considered to be relatively inac-
cessible to the immune system and should be treated with prop-
er endodontic therapy.
Obturation materials only need to be placed inside the canal
to its cavosurface margin. By knowing where the endpoint for
treatment exists (the cavosurface), better control can be devel-
oped in instrumentation and obturation of the root canal system.
Improved control goes hand in hand with improved quality in all
areas of dentistry.
The minimal apical foramen diameter also needs to be
defined. It is the smallest cross-sectional length of the apical
foramen at the cavosurface of the canal along the path taken
during instrumentation that can be determined with gauging
files. In the rare instances where the cavosurface of the canal is
at the anatomic and radiographic apex of the root, and the apical
foramen is a perfect circle, the MAFD would be the diameter of
the apical foramen (Figure 9). In most instances the MAFD will
consist of the two closest points on a plane that represent the
cavosurface of the canal. There will be many wider areas on this
plane, such as in an elliptical or irregularly shaped foramen
(Figure 10).
How can these determinations of length and MAFD be made
without radiographs? With digital radiography, taking a working
film, whether a measurement, cone fit or obturation check film,
only takes seconds and has never been easier. Why choose to
abandon these images and the information they contain? How
can it be said that better care could be delivered without them?
For me, the motive to change the way canal measurements
were obtained arose because the results that were achieved using
the information obtained from radiographs, electric apex locator,
and tactile sensation were not as consistent as desired. Often the
Figure 4: The sealer partially obscures the intimate seal developed during
results were beautiful. Sometimes, even with relatively simple obturation. What is noteworthy is the apical control that was developed in this
teeth like maxillary central incisors, the results were substan- case. Intimate knowledge of this root canal systems anatomy was gained
dard, usually an unsightly overfill, indicating a lack of aware-
ness of the specific anatomy and an inability to control treat- moments while waiting to view the post-operative radiographs.
ment in a simple root canal system. The ability to transform the Working diligently and only producing an inferior result, coupled
information from radiographs, the apex locator and tactile sen- with not understanding what precipitated the undesirable out-
sation consistently, reproducibly and accurately into technically come, make for a very frustrating endodontic experience. An
excellent endodontics fell short too often, creating anxious explanation for these inconsistent results was needed.

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measured. Then an average length discrepancy with
a standard deviation is determined.
The problem with this approximation technique
is that the teeth we treat are not average but unique.
A working length that is determined based on statis-
tical research may fall within the standard deviation.
However, the chances of getting an accurate canal
length using statistical averages and standard devia-
tions are remote. One length does not fit most
canals. The estimated length will always either be
long or short of the true cavosurface of the root. At
best this technique should be considered length
approximation, certainly not length determination.
In order to avoid over-instrumentation and over-
filling, most of us were taught to work short of the
radiographic apex. This philosophy does not address
the entire root canal system (Figure 15). Treating
short also contributes to canal ledging and block-
ages, leaving substrate in the canal for bacteria to
cause later problems.
Many of us were taught to rely on radiographs
and statistics for length ‘approximation’. Many
believe that radiographic measurements are the stan-
dard of care, or due to cognitive dissonance have
chosen to overlook the shortcomings of this tech-
nique.
The standard of care is what a reasonable and
Figure 5: A complex root canal system treated without working films. The paper point technique prudent practitioner would do. School curricula or
was used to determine working lengths textbooks do not dictate the standard of care. The
standard of care evolves as advances in the field
Endodontic treatment needs to be performed with great consis- occur. Endodontic treatment can routinely be performed without
tency in order to ensure a high predictability of results; our working radiographs and consistently produce results that meet,
patients are counting on this. if not exceed, the standard of care.

Our tradition Incorporating newer technology with


longstanding traditions
Traditionally, radiographs have been used to determine the length
of the canal. We know from many studies that this method is A new level of accuracy in length determination over radi-
inaccurate (Tamse A, Kaffe I, Fishel D, 1980). The difference ographs has been achieved with the electronic apex locator
between radiographic apex (RA) and the cavosurface of the canal (EAL). The EAL is free of the problems that visual interpreta-
can be significant. Because of the inherent shortcomings with tion of two-dimensional radiographs present. With the EAL
radiographic length determination (Figures 11-14), it has been there is no chance for our eyes to misinterpret the information
suggested by some authors that working a certain distance short that it presents. Unfortunately, the EAL is not 100% accurate
from the RA will result in a satisfactory working length (Ingle and may be perceived as difficult to use. Even though the EAL
JI, 1957; Weine F, 1982; Cohen S, Burns RC, 1998). The dis- is not infallible, it is more accurate than radiographs (Pratten D,
tance to be subtracted from the RA is based on studies where the McDonald NJ, 1996). For those of us that find it difficult to use
average distance of the apical foramen from the RA has been an EAL, there is a new product, the ‘endo Q’ (Acadental)
(Figure 16), that will dramatically decrease the learning curve
Figure 6: The
black line for mastering this device. I have found that when using the
represents the ‘endo Q’ in the hands-on courses I teach in my office, the par-
plane of the ticipants experience a dramatically accelerated learning curve.
cavosurface of
the root canal When the EAL indicates that the apex has been reached, it
means that the very tip of the file is protruding through the
foramen. Repeatedly taking larger instruments (greater than a 15
or 20 K file, depending on the curvature of the canal and the
hardness of the dentin) past this length will lead to transporta-
tion of the apical foramen, commonly known as zipping the
apex. The EAL does not accurately reveal where the canal ends
and the extraradicular structures (the PDL, bone, granulation

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Figure 7: Another view of the plane of the cavosurface Figure 8: Obturation materials need not be placed apical to the plane of the
cavosurface. As can be seen in this representation, the immune system has
easy access to the area apical to the plane of the cavosurface

Figure 9: In this idealized situation the minimum apical foramen diameter is Figure 10: In a more realistic example, the minimum apical foramen diameter is
between the arrows, which is the diameter of the circle determined from the two closest points on the cavosurface plane of the canal
along the path taken by the files used in instrumentation

Figure 11: Length determination from a radiograph can be extremely difficult Figure 12: A photograph of the radiographic specimen in Figure 11
and unreliable

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Figure 13: A radiograph of the same specimen in Figure 11 from a different Figure 14: A photograph of the specimen in Figure 11 from a different angle
angle

tissue, cyst) begins. It does not accurately reveal where to approach in endodontic treatment.
terminate treatment of the RCS.
With the EAL, a similar problem that radiographs presented Continuing the evolution of our technique
recurs – to what distance from the EAL reading should we work?
Again, studies have been done that give information in terms of What if there was a way to ‘titrate’ working length for each indi-
average length discrepancies between the EAL reading and direct vidual canal or foramen? No more underfilling or overfilling
observation (Ashraf E et al, 2002). An average distance with a unless desired. Such a method exists. It allows determination of
standard deviation is determined and adjustments to working the distance to the cavosurface of every unique canal in each
length are made accordingly. The problem, again, is in using root. This measurement can be performed to within tolerances of
averages and applying them to unique situations. Most of the 0.25mm, consistently, without radiographs. It allows us to ‘see’
time the length selected will be incorrect; either too short or too the cavosurface of the canal.
long. The beauty of this method is that once the distance to the
An example of a situation where using averages is inapprop- cavosurface of the root is known, the minimum apical foramen
riate would be when a patient is treated with IV sedation, when diameter (MAFD) at that length can be determined. Once length
titration of medications is required for safety and effect. The is determined (which means we have negotiated the canal to its
response to medications follows a bell curve. Individuals will be terminus), the MAFD at that length can also be determined; then
hyper responders, hypo responders or somewhere in between. the two variables needed to complete the endodontic equation
Unfortunately, pre-operatively it is not known how an individual successfully are known. With this knowledge comes control of
will respond. Giving an average dose of an anxiolytic agent to a instrumentation and obturation that allows the dentist to
hyper responder can result in a dangerous situation. The same determine where to terminate treatment. The results designed are
dose given to a hypo responder will be ineffective. Titration is the results produced. We can truly become masters of our
imperative in this situation for maximum safety and effect. domain.
In endodontics there also exists a bell curve with canal This measurement technique is performed with paper points.
lengths. Use of radiographs or the In addition to extremely accurate and consistent length
EAL combined with measurement information, paper points can sometimes give three-dimensional
adjustments based on average information regarding the location and slope of the apical
length discrepancy studies foramen.
inherently result in working This three-dimensional information can be extremely valuable
lengths that are excessive or in developing control
insufficient, but seldom just over the most apical
right. Unfortunately, with these extent of the canal.
measurement techniques we do There is no need to
not know which canals will be worry about
treated long, short or just right overextension of gutta
until the final film is viewed. percha. There is more
Our patients expect us to concern that fitting
treat their unique anatomy. We the gutta percha
do not usually place crowns short of the ideal
based on averages. We make a termination point will
Figure 15: Failure to treat this root unique crown for each result in obturation
canal system short of its
cavosurface could result in several
individually prepared tooth, that remains short of
millimeters of untreated tissue and we must use the same the ideal termination Figure 16: The ‘Endo Q’ for apex locator training

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Figure 17: A paper point will stay dry in a canal if it is short of the cavosurface Figure 18: When the paper point is overextended, capillary action may allow
of the canal excessive fluid to collect on the point

Figure 19: The apical extent that the paper point can be placed to, and remain Figure 20: As soon as the paper point is extended past the cavosurface of the
dry, is recorded as the length to the cavosurface of the canal canal it will be discolored

point. With good apical control, the gutta percha cone will environment is living and hydrated. There is the PDL,
not advance, even under the pressure developed by vertical granulation tissue, pus, blood, bone or some other hydrated
condensation forces. tissue containing fluid that exists beyond the cavosurface of
When we are lacking length or minimal apical foramen the canal.
diameter information, we cannot attain the same degree of If a paper point is placed into a dried canal and removed short
control. In these situations we need a little bit of luck to help us of the apical foramen it should be retrieved dry (Figure 17). If a
pull it off. Gifted clinicians can pull it off routinely, intuitively paper point is placed into a dried canal and taken past the
knowing and feeling the variables. But for those of us that might cavosurface of the canal it will be retrieved with fluid (blood,
need to take a few practice swings before going on the golf pus, serous fluid, or mucus) on that portion of the point that
course, or maybe even need a lesson now and then, it is nice to extended through the cavosurface of the canal. Due to capillary
have all the information we could possibly need. Wouldn’t you action, the wet portion will be extended some distance further
like to know the exact yardage for your golf shot, the exact slope along the point than the portion that was directly in contact with
and speed of the green? Tiger Woods has a feel for it. Most oth- the fluid (Figure 18). The length of paper point affected by this
ers would like all the help they can get. capillary action is dependent on the viscosity of the fluid present
beyond the canal and the absorbency of the paper point. We do
The point not need to know this information to get accurate length
information from paper points.
The concept behind paper points being used to provide accurate The technique for paper point measurement can be simple.
length information comes from the idea that when the contents Place a paper point into a dried, patent canal. A trial paper point
of the root canal system are removed the canal should be is placed 1mm short of the EAL length. If the point comes out
dry. The extraradicular (or more accurately extracanalular)

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dry, advance it until it picks up some fluid. Note the length of instruments that have taken place, notably the introduction of
the point that is dry. Now, another point is taken just short of this greater taper files.
length, remove and observe. For this example, assume that the
point comes out dry (Figure 19). Re-introduce and advance the References
point until the very tip of the point has the slightest bit of fluid
on it (Figure 20). The point should not remain in contact long Ashraf E et al (2002) The ability of root ZX apex locator to reduce the frequency of
enough for any capillary action to have taken place. Record the overestimated radiographic working length. J Endodontics 28: 116-9
maximum length that the point can be placed into the canal and
remain dry as the length of the canal. This is the cavosurface of Buchanan LS (1991) Paradigm shifts in cleaning and shaping. J. California Dental
the canal Assoc. 23: 24-34
Now that an accurate canal length is known, the MAFD at this
length can be determined. By taking K-files to the paper point Cohen S, Burns RC (1998) Pathways of the Pulp. 7th ed. CV Mosby
length without rotating them, but with apical pressure, a file that
will not go long but will bind at, or just short of, paper point Ingle JI (1957) Endodontic instruments and instrumentation. Dental Clinics of
length will be found. This file represents the MAFD. North America. Nov: 805-22
Of course there are some subtleties to the technique. In
teaching this technique for the past few years I have also become Tamse A, Kaffe I, Fishel D (1980) Zygomatic arch interference with correct
aware of the common problems and misconceptions that dentists radiographic diagnosis in maxillary molar endodontics. Oral Surg 50: 563-5
new to the technique have in common. In part two I will address
several of these issues and offer solutions. Pratten D, McDonald NJ (1996) Comparison of radiographic and electronic
working lengths. J Endodontics 22: 173-6

Conclusion
Weine F (1982) Endodontic therapy. 3rd ed. St. Louis: CV Mosby
It is my hope that this article will facilitate quality endodontic
treatment by taking advantage of the developments that have
taken place in the last decade. The paper point technique would The author would like to thank Dr Gary Carr for his mentoring
not be a consistently reproducible technique without advances in

CPD
This article is equivalent to one hour of verifiable CPD. To the foramen.
receive credit, complete the multiple choice test after each article b) The EAL only indicates when extraradicular structures are reached by files
and return for processing. Answers can be posted to Endodontic c) The zero reading indicates the position of the MAFD at the cavosurface
Practice Verifiable CPD, FMC Ltd, NAT2688, Shenley WD7 9BR only.
(no stamp required within the UK), faxed on 01923 851778 or d) Studies on EAL accuracy indicate discrepancies in EAL readings and
emailed to cpd@fmc.co.uk. direct observation of the MAFD.
Please include your name, address, subscriber number, GDC
registration number and the reference code ROSEN/MAR/04. Q3
Which of the following comments on the measurement technique advocated
Q1 in this article are incorrect?
Which of the following comments regarding the cavosurface of the canal a) The environment beyond the canal is living and hydrated.
and minimum apical foramen diameter (MAFD) are incorrect? b) The paper point will indicate the diameter of the MAFD.
a) The most apical portion of the canal is the demarcation of internal canal c) The paper point will indicate the position of the cavosurface.
and external root. d) The paper point can provide three dimensional information regarding
b) The anatomic and radiographic apex represent the cavosurface of the location and slope of the apical foramen.
canal.
c) Obturaton materials are better placed apical to the plane of the Q4
cavosurface. The paper point technique involves which of the following stages?
d) In the majority of instances the MAFD is determined from the two a) Advance the paper point until capillary action draws tissue fluid up the
closest points on the cavosurface plane along the path taken by the files point.
used in preparation. b) Advance the point until it is just in contact with tissue fluid.
c) Record the most apical position of the dry point.
Q2 d) Use a K-file that just slips through the measured position to assess the
Electronic apex locators (EAL) are not 100% accurate in locating the end MAFD.
point of preparation and filling. Why? e) Use a K-file that binds ‘snugly’ at the measured position to assess the
a) The zero reading indicates that the file tip is protruding through. MAFD.

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