Synopsis Report

Submitted as partial fulfillment of the requirement for FCPS-II

SYNOPSIS ON

Qualitative Comparison of working length by using radiographs and Electronic Apex Locator and its effect on the adequacy of final working length
Submitted By:
Dr. Saba Hafeez FCPS-II TRAINEE

SUPERVISOR: Dr. Naghma Parveen BDS, MCPS, FCPS Head of Department of Operative Dentistry Unit-II Nishtar Institute of Dentistry, Multan

Nishtar Institute of Dentistry Multan

Dr. Saba Hafeez

Synopsis Report

The Director, Research Training and Monitoring Cell, College of Physicians and Surgeons Pakistan 7th Central Street Phase II, Defense Housing Authority-Karachi-75500 Dear Sir, Enclosed herewith please find synopsis titled: Qualitative Comparison of working length by using radiographs and Electronic Apex Locator and its effect on the adequacy of final working length Prepared by: As a pre-requisite of FCPS-II trainee in subject of: RTMC allotted Registration No: Submitted on Trainees Signature: Name of Supervisor: Qualification: Designation: Name of Training Institution: Dr. Naghma Parveen BDS, FCPS, MCPS Head of Department of Operative Dentistry Unit II Nishtar Institute Of Dentistry, Multan Dr. Saba Hafeez Operative Dentistry DSG-2011-099-917

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Synopsis Report

Yours sincerely, Dr. Saba Hafeez

Supervisor Signature

Official Stamp

Qualitative Comparison of Working length by using radiographs and Electronic Apex Locator and its effects on the adequacy of final working length Root canal preparation techniques aim to end the biomechanical instrumentation at the apical constriction.1 Root canal terminating at the apical constriction provide optimal healing conditions with minimal contact between the filling material and the apical tissues, thus reducing tissues destruction, persisting inflammatory responses and foreign body reactions2. The ideal limit for chemical and mechanical preparation is the cement dentinal canal junction(CDJ) because this is where the canal usually presents its lowest diameter and where the dentinal and cementum canals meet.3 Determination of an accurate working length is one of the most critical steps of endodontic treatment. The cleaning, shaping and obturation of the root canal system cannot be accomplished accurately unless the working length is determined precisely.4-5 Working length is defined in the endodontic glossary as the distance from a coronal reference point to the point at which canal preparation and obturation should terminate 6 Traditionally radiographs are used to determine the working length, however radiographic assessments of working length may prove inaccurate depending on the direction and the extent of the root curvature and the position of the apical foramen in association with the anatomic apex 7. The development and production of electronic devices for locating the canal terminus have been major innovations in root canal treatment8 .The development of electronic apex locators has helped to make the assessment of working length more accurate and predictable9.

Dr. Saba Hafeez

Synopsis Report

The advantages of apex locators include equal or higher accuracy compared with the radiographic method, continuous monitoring of the working length in combination with intelligent rotary system, discriminating between impenetrable and penetrable canals and reducing the total radiographs needed and radiographic exposure. Their limitations include over preparation in retreatment when combined with the rotary systems, premature showing of apex on rare occasions and inconsistent measurements. The previous studies has shown a higher but not statistically significant rate of acceptable results(90.4%) regarding master cone radiography in the Electronic Apex locators and (82.1%)in radiographs.
10

Several studies have investigated these two methods solely or in

comparison but randomized clinical trial studies that compare these two methods with each other in a truly clinical conditions are scarce The rationale of this study is to compare qualitatively the working length by radiographs and electronic apex locator and its effect on final working length Objective The objective of this study is: To compare qualitatively the working length by using two different methods i-e Radiographs and Electronic Apex Locator (EAL) and their effect on the adequacy of final working length. Operational Definition Final working length: The distance from a coronal reference point to the point at which canal preparation and obturation should terminate. Adequacy: The quality or state of being adequate is fulfilled when: 1. Master Cone Length with Electronic Apex Locator and Radiographs is within 0-2mm of apex 2. Final Obturation Length with Electronic Apex Locator and Radiographs is within 0-2mm of apex

Dr. Saba Hafeez

Synopsis Report

Hypothesis: Electronic Apex Locator is more adequate in working length determination as compared to radiographs Materials and Methods Study Design: Randomized Controlled Clinical Trial Setting: Department of Operative Dentistry Unit II, Nishtar Institute Of Dentistry, Multan. Duration: Six months after approval of synopsis Sample Size: n=186 (93 in each group), sample was calculated using following formula. n= p1q1+p2q2/d2 where p1=82.1 q1=100-82.1=17.9 p2=90.4 q2=100-90.4=9.6 d2=5% Sample Technique: Non probability purposive sampling Sample Selection: Inclusion Criteria:

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Synopsis Report

1. Patients of both genders between age 15-40 years. 2. Patients with symptomatic irreversible pulpitis clinically and radio graphically in mandibular and maxillary anteriors and premolars. 3. Teeth with mature apices and without root resorption. Exclusion Criteria: 1. Severely curved roots radio graphically 2. Patients having limited mouth opening. 3. Physically and mentally handicapped patients. 4. Patients with cardiac pace-makers. 5. Cases in which radiography alone because of superimposition was not enough to determine working length. 6. Teeth with no apical patency due to any cause. Data Collection Procedure The study will be carried out on patients visiting the operative outdoor department of Operative Dentistry Unit II, NID Multan for treatment of their mandibular and maxillary anteriors and premolars will be selected after fulfillment of inclusion criteria from out patient department of NID. Ethical issues will be considered and managed during the study after approval from the hospital ethical committee. The demographic information like name, age, gender and address will be obtained. After history taking and clinical examination of the oral cavity patients will be randomly allocated into two equal (group A, group B) each comprising of 93 patients on random basis using a random number table. Group A working length will be determined by using radiographs and in Group B with electronic apex locator. After taking history and clinical examination of the oral cavity, pre-operative periapical radiographs of the teeth will be taken of each patient. For patient in each group teeth will be anaesthetized using local anaesthesia i.e. Lignocaine with Adrenaline in a ratio of 1:100,000, isolated with rubber dam and access cavity will be prepared. In Group A(n=93) working file will be placed to the estimated length and taking the working length radiographs, the primary working length will be determined to 1mm short of radiographic apex. Canal preparation will be finishes to this working length and after

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Synopsis Report

inserting master cone to this length master cone radiograph will be taken. Correction of working length to 1mm short of radiographic apex will be made if needed and this will be the final working length. Canal will be obturated to the final working length using lateral condensation technique. Final radiograph will be carried out. In Group B (n=93) working file will be placed to the estimated length after access cavity preparation according to the preoperative radiographs, file clip of IPEX (4th generation precision apex locator, NSK) will be attached and will move towards the apex until dental mark on the LCD start flashing, the file will be withdrawn just to the point when dental mark will stop flashing. The length of the file will then measured at this point and 0.5mm will be subtracted. Canal preparation will be finishes to this working length and after inserting master cone to this length, master cone radiograph will be carried out. If the tip of Gutta percha will be shorter than 0-2mm of the apex, correct it to be 1mm short of the apex otherwise it will not change. Canal will be obturated to the final working length using lateral condensation technique. Final radiograph will be carried out. The Proforma is attached as Annexure-1 on page 9 Data Analysis Procedure Data will be entered and analyzed using computer program SPSS-11. Descriptive statistics will be applied to calculate mean and standard deviation for the quantitative variables like age of the patients. Frequencies and percentages will be calculated for the qualitative variables like gender, Radiograph and Electronic Apex Locator. Chi-square test will be applied to compare the outcome variable in both groups. P value equal or less than 0.05 (p 0.05) will be considered as significant value. Confounders like age and gender will be controlled by stratification.

Dr. Saba Hafeez

Synopsis Report

References: 1. Bernardes RA, Duarte MA, Vasconcelos BC, Moraes IG, Bernardineli N, Garcia RB et al. Evaluation of precesion of length determination with 3 electronic apex locators: Root ZX, Elements Diagnostic Unit and Apex Locator and Romi apex D-30. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104:91-4. 2. Plotino G, Grande NM, Brigante L, Lesti B and Somma F. Ex vivo accuracy of three electronic apex locators:Root ZX,Elements Diagnostic Unit and Apex Locator and ProPex. Int Endod J 2006; 39:408-14. 3. R eal DG, Davidowicz H, Moura-Netto C, Zenkner Cde L, Pagliarin CM, Barletta FB, de Moura AA. Accuracy of working length determination using 3 electronic apex locators and direct digital radiography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111:444. Ehsan S, Comparative Role of Radiographs and Electronic Apex Locator in Working Length Dtermination. Pak Oral Dental J 2011; 31:187-90. 5. . Ingle's JI & Slavkin HC. Modern Endodontic Therapy;Past,Present and Future. In P Bindner editor. Ingles endodontics 6. Hamilton: BC Decker; 2008. p.25-35 6. Vieyra JP, Acosta J, Mondaca JM. Comparison of working length determination with radiographs and two electronic apex locators. Int Endod J 2010; 43:16-20. 7. Kim E, Marmo M, Lee CY, Oh NS, Kim IK. An in vivo comparison of working length determination by only root-ZX apex locator versus combining root-ZX apex locator with

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radiographs using a new impression technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105:79-83 8. Neekofar MH, Gandhi MM, Hayes SJ, Dummer PMH. The fundamental operating principles of electronic root canal length measurement devices. Int Endod J 2006; 39:595609. 9. Higa RA, Adorno CG, Ebrahim AK, Suda H. Distance from le tip to the major apical foramen in relation to the numeric meter reading on the display of three different electronic apex locators. Int Endod J 2009; 42:1065-70. 10. Ravanshad S, Adl A, Anvar J. Effect of working length measurement by electronic apex locator or radiography on the adequacy of final working length: a randomized clinical trial. J Endod 2010; 36:1753-6.

PROFORMA

(Annexure I)

Qualitative Comparison of working length by using radiographs and Electronic Apex Locator and its effect on the adequacy of final working length

Patients name: Gender: Address: Date: Group A: Initial Working Length: Radiography

Age: Registration no:

Diagnosis: Group B:

Electronic Apex Locator

Master Cone Length Adequacy: Short <2mm from Acceptable0-2mm Over(beyond apex)

Dr. Saba Hafeez

Synopsis Report

radiographic apex Radiography Electronic Apex locator Final Obturation Length Adequacy Short <2mm from radiographic apex Radiography Electronic Apex Locator Yes/No Yes/No Yes/No Yes/No Yes/No Acceptable0-2mm Over(beyond apex) Yes/No Yes/No Yes/No Yes/No Yes/No

Dr. Saba Hafeez