JOURNALOF ENDODONTICS
Copyright © 1999 by The American Association of Endodontists
CLINICAL ARTICLES
Effect of Preflaring on Root ZX Apex Locators
Jose L. Ibarrola, DDS, MS, Brent L. Chapman, DDS, James H. Howard, DDS, MS,
Kenneth I. Knowles, DDS, MS, and Marvin O. Ludlow, DDS, MS
The Root ZX apex Iocator is an example of a gener-
ation of apex Iocators that identify the terminus of the
canal by measuring a ratio between two electrical
impedances. Studies have shown this device to have
a high degree of accuracy. However, the manufac-
turer warns that the performance of these devices is
limited by the presence of calcifications and dentinal
shaving obstructions. An in vitro study was designed
to determine if preflaring of canals would facilitate
the passage of files to the apical foramen by elimi-
nating cervical interferences and to see what effect
this would have on the performance of the Root ZX
apex Iocator. Thirty-two canals were divided into two
groups. Group 1 was not manipulated before use of
the Root Zx apex Iocator and served as control. In
group 2, the canals were preflared before the use of
the Root ZX apex Iocator. The working length files
were secured in place and measured with the linear
measurement tool used by the Visilog 5 imaging pro-
gram. Results of this study suggest that preflaring of
canals will allow working length files to more consis-
tently reach the apical foramen (p = 0.015), which
in turn increases the efficacy of the Root ZX apex
Iocator.
In 1942, Suzuki (1) found the electrical resistance of the periodontal
membrane and that of the oral mucosa to share a constant value of
- 6 . 5 kiloOhms. In 1962, Sunada (2) applied this principle to clinical
practice by incorporating this resistance value into the electronic
circuitry that was contained in prototype electronic canal measuring
devices. These devices allowed measurement of the canal length by
comparing the electrical resistance that was built into the apex locator
with the resistance between the tip of the file and that of the peri-
odontal membrane. Ensuing technology that measured the ratio be-
tween two electrical impedances emitted from a probing instrument
was applied to the circuitry of newer generation electronic apex
locators. This allowed these devices to circumvent some of the lim-
itations of electrical resistance type apex locators, which could not be
used in the presence of electrolyte-containing solutions, such as so-
dium hypochlorite or blood, limiting their usefulness to relatively dry
canals. Fouad et al. (3) showed that impedance type apex locators
could be accurately used in the presence of various electrolyte-con-
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VOL. 25, No. 9, SEPTEMBER1999
taining solutions. A number of these devices have been introduced in
the market. Studies have placed the accuracy of these devices in the
range of 83% to 93.4% (4). Shabahang et al. (5) specifically tested the
accuracy of the Root Zx apex Iocator (J. Morita Corp., Kyoto, Japan)
in vivo and located the apical foramen of 26 vital teeth with an
accuracy rate of 96.2%, while allowing 0.5 mm for margin of error.
Lack of patency and accumulation of debris in canals have been
reported as impediments tbr the establishment of accurate working
lengths. Stabholtz et al. (6) analyzed the effect that prefiaring of canals
might have on the tactile sensitivity of operators who attempted to man-
ually locate the apical constriction, and tbund preflaring of canals to
significantly enhance the tactile sensitivity of the investigators. They
observed that the geatest binding of files occurred in the coronal third of
canals and that by enlarging the canal orifices and eliminating cervical
interferences, files could be passed more easily to the apices of teeth.
Calcifications and accumulation of dentinN shavings are said to interfere
with the performance of electronic apex locators (7), and it has also been
shown that packing of debris in the apic'al third of the canal will affect the
accuracy of these devices (8). It is not known what effect the elimination
of cervical interferences has on the pedbrmance of electronic apex loca-
tors. An in vitro study was des;gned to determine it" preflating of canals
would improve the efficacy of Root ZX apex locators.
M A T E R I A L S AND M E T H O D S
Sixteen mesial roots of mandibular molars were used for this
study. Only roots with Weine's type III canal configuration were
used, giving a total of 32 canals. The canals were then divided into
2 groups of 16 canals each. In group 1, the canals were not
manipulated before utilization of the electronic apex locator and
served as the control group. Group 2 was the experimental group
in which the canals were preflared before using the electronic apex
locator. An in vitro model similar to the one that Aurelio et al. (9)
used to compare the accuracy of several electronic apex locators
was used in this study. This model consists of a test tube filled with
an agar suspension that was mixed with saline solution with a nail
inserted at the bottom of the test tube to complete the circuit. In our
study, the agar was substituted with commercial gelatin as de-
scribed by Czerw et al. (10). After gaining access, the pulp cham-
ber was irrigated with distilled water to remove any debris. Canals
in group 2 were preflared with Profile .04 taper rotary instruments
(Tulsa Dental Products, Tulsa, OK) sizes 9 to 6 in a crown-down
fashion. Canals were again irrigated with distilled water.
A #10 file was introduced into all of the canals, and the elec-
tronic apex locator was connected to the ground nail that was
 626 Ibarrola et al. Journal of Endodontics

TABLE 1. Distance (mm) from apical constriction to tip of file TABLE 2. t test: paired two samples for means

Prefiared Canals Unflared Canals (Control) Preflared Unflared

0.00 -0.16 Mean 0.048125 0.42125
-0.90 0.00 Variance 0.11227 0.386785
-0.21 0.22 Observations 16 16
0.28 0.48 Pearson correlation 0.279815
0.00 0.00 Hypothesized mean difference 0
0.00 1.09 df 15
0.19 0.30 t Statistics 2.41343
0.00 0.04 p (T _-< t) one-tailed 0.014526
-0.13 1.95 t critical one-tailed 1.753051
0.41 0.19 p (T <= t) two-tailed 0.029052
0.67 1.73 t critical two-tailed 2.131451
0.31 0.13 Statistical analysis shows that the Preflared results are significantly different from the
0.00 0.00 Unflared results (P 0.015).
0.00 0.23
0.00 0.34
0.15 0.20
We also found the model described by Aurelio et al. (9) to be reliable
when testing apex locators in vitro, because most of the samples were
inserted into the test tubes. After establishing apical patency, the right at or within 0.5 mm from the apical constriction. In our opinion, the
files were clipped to the file holder of the apex locator and higher accuracy observed in the preflared group was due to the ability to
advanced apically until the indicator display showed that the apical more consistently have unimpeded access to the apex by removing
foramen had been reached. interferences that were coronal to the apical third.
The files were then secured in place by tkst applying cyanoacrylate It would have been of interest to see if measurements changed
cement, and then filling the pulp chamber with a fight-cured resin. Mesial within the same canals before and after preflaring. However, this was
roots were sectioned with a fissure bur ha a high-speed handpiece. These not possible because the files had to be secured and the roots thinned
roots were then thinned with a sandpaper disc until the apical foramen and in order to use the Visiliog 5 linear measurement tool. Overall, the
tip of the file became visible. Samples were analyzed with a Leica DML Root ZX apex locator was found to be an accurate measuring instru-
microscope that was calibrated at ×2.5 ma~litication and a measurement ment. In 14 of 16 pmflared samples, the apex locator reading was
was made from the apical constriction to the tip of the file with the linear within 0.5 mm of the apical constriction. In the nonfl~ed group, the
measurement tool used by the Visilog 5 imaging software progrmn apex locator reading was within 0.5 mm in 13 of 16 samples.
(Noesis Vision, Quebec, Canada). Measurements were compiled and The results of this study showed a statistical difference between
statistically analyzed. the means of the two groups, which suggests that more consistent
results were obtained in the preflared group. However, the clinical
RESULTS significance of these findings might be limited, because measure-
The distances obtained in all samples, between the apical con- ments in both groups were comparable with a mean of 0.04 on the
striction and the tip of the file, are presented in Table 1. A negative preflared group vs. 0.4 in the control group.
number signified the distance that the file extended past the apical
Dr. Ibarrola is assistant professor, Department of Endodontics; Dr. Chap-
constriction. A t test, comparing the means of the two groups man is a former fourth-year student; Dr. Howard is associate professor,
(Table 2), showed the preflared group to be significantly different Comprehensive Dental Care; Dr. Knowles is associate professor, Department
from the control group (p = 0.015). The mean of the experimental of Endodontics; and Dr. Ludlow is chairman, Department of Endodontics,
Creighton University School of Dentistry, Omaha, NE. Address requests for
group was 0.04 mm vs. 0.4 mm for the control group. reprints to Dr. Jose L Ibarrola, Creighton University School of Dentistry, 2500
California Plaza, Omaha, NE 68178.
DISCUSSION
The results of this study show a statistical difference between the two References
groups. However, all canals where canal patency was maintained showed
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