Determining tooth length with bisecting angle radiographs

BARBARA IILLIN(;. MD and ADI KARMON'. DMD

Deiitiil Mcdivim; Jcnisulcm, Isnwl

Hchrc\v University - Hadassah School of

The precise determination of the length of a tooth Is an iin|)ortjnt factor in rool canal treatment.
It is the first step before (he chemo-niechanical cleansing, enlarging and filling ol" the root
canal. (Allred et al (1961) and Best et ul (I9G0)).
During the past few years, various methods have been devised for calculating the length oi' the
tooth. Sunada (1962) and Gordon (I960) used the electrical resistance of the apical area for direct
nieasurenienl by means of a metal electrode inserled into the root canal.
Best et al (I960) described a specific measuring scale which could be applied to diagnostic
radiographs in order lo {)blain the correct length. Allhough this nieihod is successful in measuring
leeth which have relatively straight roots, it cannot be applied to those teeth which have marked
curvature in the apical third, as is often found in poslerioi icclh.
It was the object of this sludy lo examine the usefulness and accuracy of the bisecting angle
radiographic technique in delennining tooth length, to assess the inaccuracies and distortion produced using this technique, and to determine how iliese inaccuracies can he minimized.
Materials and Methods
The investigation was performed on 50 extracted leeth. with various rool Torins. There were IS
maxillary and niandibtilar anterior teeth (13 incisors and 5 canines); 17 maxillary posterior leeth
(8 premolarswith 12 canals and 9 molars with 23 canals) and 15 mandibniar posterior teeth (6
premolars and 9 molars with a total of 25 canals).
I or simplicity it was decided ihat all the anterior ma.villary and mandibuhir teeth would be
considered as one unil to arrive at the desired statistics for the variables included.
Access lo the pulp chambers was made on llie lingual surface oi \\\c anleiioT leelh. and the
occlusal surface of the posterior (eeth with a high-speed htir. A root canal file with a rubber marker
was inserted into each root canal until it was just visible at tbe apical foramen. Tlie rubber marker
was adjusted on the file until il was level with incisal edge or the occlusal surface. Iiach Hie was
then carefully removed from Ihe c;inal and the distance from the rubber marker was measured on a
millimetre scale. This measurement was taken lo repteseiU Ihe true length of tlie tooih.
The teeth were then inserted into a Columbia Dentofonn* rubber mould in their appropriate
positions within the dental arch. Selfcuring acrylic resin was then mixed and poured into the
moulds around Ihe teeth and allowed to polymerise.
The acrylic models containing the teeth were removed iVdni the moulds. A winged rubber dam
damp was attached to each tooth in turn, a root canal file complete with marker was then inserted
into the root canal ;is far as the apical foramen nnj a radiograph taken. Care was taken lo ensure
that the rubber marker was adjusted until Hush with the occlusal or incisal surface. In the case ol
muMirooted teeth. Hies were inserted inio each c;uial.
'Subriiillcd in p;irli;il luirilfiiciil "I Hie rL-iiiiiri;menls (or Ilio DMD degree.
Columbia Denldfonn Corporatiim. New Ynrk.

Journal of flic liritish luidodonlic Society 197b Vol 9 No 2

75

B. Haling and A. Kannon

Using the standard bisectiiig-irngte method, ;i radiograph oiciidi tooth was taken using Kodak
ultra-fast film exposed witii a 65 kV, lOina X-ray machine, at 20 cm target to film distance. A
second radiograph of each tooth was taken, using a non-orthoradial cone aiigulation.
The nie was removed from the tooth and measured from marker to tip, and from the lower
border of the handle to the tip.
The following measurements were recorded from the two radiographs of each tooth, using
dividers and a millimetre scale:
(1) 'foolh lengtli to apical foramen.
(2) File length from tip to marker.
(3) File length from tip to iiandle.
The actual length of tooth was calculated using three separate formulae.
, ,
,
J.
,.
, ,
,
known nie length
A. Actual tooth length = radiographic tooth length x p
r- ri.,i ,,.i
^
^ '
radiographic tile length
, ,
,
,.
,.
, ,
,
known file length to marker
B. Act.,al looth length = rad.ographic tooth length x ..^j^graphic IHe length to marker
C. Actual tooth length = known file length distance the radiographic image of the file is short
of, or extends heyond the apical foramen. (If the distance is greater than 2 mm, it is
multiplied by the percentage distt)rtion, whieh is derived by comparing known and radiographic file lengths.)
Restilts
Table I shows Ihe comparison of the three methods of calculating tooth length from radiographic
image and file measurements.
The correlation between radiographic dimensional distortion and looth position within the
dental areh is presented in Table II. Distortion was assessed by the appearance of the occlusal, or
incisal tooth surface relalive to the position of the rubber marker. The marker was adjusted to be
level with either the occlusal or the incisal surface before taking the radiograph.
Table 111 shows the correlation between measured tooth length and the radiographic image
length. The length of anterior teeth was magnified 5.5% in the radiograpliic image. Similarly,
maxillary posterior teeth were magnified 5.1% and mandihular posterior teeth 4.1%.
Tabtc !. Coinpiitisuii of iiii;UuHis lur radio};r;ipliii.:i!ly delcrruiiiiiii; toulb k-iii^tli

Method

No of root
canals

17
16
17
16
17
16

I,

76

28
26
28
io
26

X-ray angulation

Avcrat;c ditTerciicc in mm
between measured
and radiugraphicully
determined tootb lengtb

Maxilhirv and niandihular anterior iccth

P
0.6

BA
P
BA
P
BA

P
BA
F
P
BA

0.6
0.1
0.4
0.2

0.1
Maxillary posterior teeth

0.6
0:7
U^
OJ
0.4

Standard
deviation
(r)

0.44
0.44
0.23
0.39
0.39
0.33

0.59

Journal of ihc British Endodontie Society 1976 Vol 9 No 2

Detenniiung tooth length

Table t. (.*ornp:iri^iMi ul mcilnuls lor r;iili(>t;r;ipliic;illv ilctcrniining loolli Icniil
Avi'rapf dilYL-KMiL-f in inrTi
l)i.-uv'i.'(.'n measured
and r;idi()s:rapliieally
detLTiniiiL'd loolh lemitli

No of
Method

X-rav ampliation
28
26

V
UA

25
J7

V
BA
P
BA
P
BA

25
17
25
19
UA

Maxillary posterior teeth

0.5
0.4
Mattdihiilar jiostcrior teeth
0.5
O.
0.4
0.7
0.3
0.3

Slandard
deviation
(r)
0.41
0.46
0,59
0,53
0.43
0.67
0.37
0.41

ccli-d Ant;lL-.

Table II. Correlaliun between radi<ii:raplii(.-tlimeiisioiial dislnrtinn and toolli posilion wiiliin the dental arcli
Maxillary poslerior

Mandihtilar poslerior

Anterior teeth

lectli

teeth

Nodfroi i l

No of root
cunal.s

canals
3
6
9

No distortion
Sli)^hl diiU
Distortion
'Iolal

16.7
33.3
50.0

18

IOO

28.6
50.0
21.4

10
17
8
35

100

No of rool
canals

%
32.0
64.0
4.0

8
16
1
25

100

Talik III. Corrclalioii lieivleen mea:surcd UKUII Icnj: III ami llie railiofrruphii: iin;i^e ienglh

louih

No ol' root
canals

Anterior
Maxillary posterior
M;in(libiilar pu.stcrior

18
35
25

Magnification
5.5%
5.1%

C'nrrei; iiion
ient (r)
0.879
0.858
0,929

Discussion
Tlie inosi widely used method for determining tootli lenglli is a method of proportion which uses
Ihe ronmila:
al lot)th lcimlh
Radiographic toolli Icnglli

Known llie
Riidi()j;r;iphic Hlc lenyth

r"or the purpose of tliis study, this was known as metliod A.

A nuKlification oClhis. (inclhod B),does not require measiiring Ihc wlinic lengih nC the file but
only from the tip to (lie rubher marker having been previously adjusted to Ihc level with t!ie
occlusal or the incisal surface of the tooth.
Jottrnal of the British Endodotitic Society 1976 Vol 9 No 2

B. Heling and A. Kannun

The third method is described by Ingle (1957). Nicholls (1^67} and Allred et al(1961): Actual
tooth length = Known length of file to stop distance by which file is short of or extends beyond
the apical foramen. This was denoted ;is method C.
In Ihis statistical comparison of these ihrce methods, ihe most accurate results were obtained
liy method C, the smallest dilTerence between the previously measured tootli length and thai
calculated from the formula was observed by this method. Also, the standard deviation in method
C was smaller llian that produced by either A or B.
The criticisms against methods A and B are that besides being unnecessarily complex, small
i;i;iccunic(es in (he measuremenls will magnify the resultiinl error (Nicholis 1967),
In methods A and B, an attempt is made to measure the radiograpliic longitudinal distortion by
comparing the radiographic length of the file with the known length. 1 lowevcr, this distortion is
not necessarily constant throughout the length of the tooth, due to such faetors as divergence of
the X>ray beam and the bending of the film.
Comparing tbe methods, the results produced in A were less accurate than tbose of B, since in
the former, tbe whole length of the ille is measured compared witb the shorter length of file to
rubber stop in tlic latter.
Method C presents very few of the previously described deficiencies, as only the relatively
small distance by wliicb the file is short o\\ or beyond the apical foramen, is measured. Therefore
a sligfit radiographic distortion will cause an error of only a fraction of a millimetre in estimating
tbe total length of the canal, this according to Nicholls (1967) is within tolerable limits.
Inaccuracies in measuring distances on the radiograph are particularly likely where tlie tooth is
curved, since measurements have to be made along the curve. In this case, the inberent
inaceuracies of methods A and B would be considerably multiplied.
In the comparison of tooth length the determination using the long cone paralleling and the
bisecting angle or non paralleling technique, it was found that in methods A and B, the results
produced from the long cone radiographs were more accurate than wben using the bisecting angle
radiographs. In method C, no statistically significant difference was obtained.
However, in multirooted teeth, especially maxillary premolars and tbe mesial roots of
mandibular molars, the buccal and lingual canals will be superimposed and appear as one canal in
a bisected angle radiograph. By altering the horizontal angulation of the X-ray beam the canals
will be seen separately (Updegrave 1961).
Updegrave (1959) stated that dimensional distortion is a direct product of the bisecting angle
technique. Tbis phenomenon is particularly noticeable in endodontie radiographs. During root
canal treatment the tooth is isolated frt)m tbe rest of the oral cavity by means of a rubber dam and
clamp. The operator is somewhat obstructed in his placing ofthe fihn close to tbe tooth by tlie
presence oi" the clamp. Because of the increased object-film distance, both longitudinal and
dimensional distortion will be increased. This is particularly seen in the maxillary arch, where
palatal contour is an additiunal limiting factor in ideal film positioning (Sunada 1962), and in the
anterior region of tbe mandibular arch, due to the converging bodies of the mandible whieh do not
permit close appro.\imation of the film to the lower anterior teeth.
Tbese factors were conOmied in our correlation between radiographic dimensional distortion
and tooth position within tbe dental arch (p 0.01).
Ill measuring radiographic tooth length as is required in methods A and B, it is essential to
measure not from tbe apparent incisal edge, but from the base of the tlie which is a more accurate
78

Journal of the British Endodatitic Society 1976 Vol 9 No 2

Dctennitiitig tooth length

rcprcsenlalion of the position of the incisjl edge. This phenomenon is also seen when a rubber stop
is alt:iched lo the Hie as is the case with almost ever>' tooth iiiidcrgding root caiul treatment.
(Langhind and Sippy l''66).
)i;irr and Gr0n (l')5')) founti that paialleliiig technique radiographs prodticcd virtually correct
orientation of all the Mruclures depicted, hut also a longittidinal image magnificalioii ofS -10%.
Vaiide VotHiie and Ujorndlial (i'>6'J), found that in anterior teelh, the tooth image was magnified
5.4% with this technique.
In our correliiUoii hclween aclua\ tnolh length and the radiograpluc image length, U was found
that anlerior maxillar>' and niandibular teeth, were magnified 5.5% in the radiograph. In maxillary
posterior teeth, magnification was 5.19? and in iniuidibtilar posterior teeth 4.1%.
These resulls compared favourably with those obtained wiili the paralleling technique, especially
considering that the teeth in our stndy had a rubber dam clamp attached to them, thereby increasing ihe possibility t)f dislorlioii. The teeth in the paralleling technique studies wore radiograpbed
without clamps.
Summary and Coneliisions
A comparison was made of measured lootii lengtli and tooth length c;ilculaled from mea.surements
of radiographs.
The most accurate results were obtained liy llic ineihott which uses the formuUi:
Actual tootb length = known length of root canal file radiographically determined distance by
which file is short of, ox beyond the apical foramen.
Bisecting angle radiographs were found to be adequate for determining looih length in
endodontic procedures.

References
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UKS1\

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79