Aust Endod J 2017

ORIGINAL RESEARCH

Influence of different sized files on the accuracy of two electronic

apex locators
Fernando A. Orosco, PhD1; Guilherme F. da Silva, PhD1 ; Paulo H. Weckwerth, PhD1; Maria Thereza M.
^ nio H. Duarte, PhD2; and Ivaldo G. de Moraes, PhD2
Lopes, DDS1; Alan M. R. Garcia, MSc1; Marco Anto
1 Pro-Rectory of Research and Post Graduation, Universidade do Sagrado Corac~ao, Bauru, Brazil
2 Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of S~ao Paulo, Bauru, Brazil

Keywords
apical foramen, electronic apex locator,
endodontics, root length determination.
Correspondence
Dr Guilherme F. da Silva, Pro-Rectory of
Research and Post Graduation, Universidade
do Sagrado Corac~ao, 10-50 Rua Irm~a Arminda,
Bauru 17011-160, SP, Brazil.
Email: gferreiras@hotmail.com
doi: 10.1111/aej.12235
(Accepted for publication 14 August 2017.)
Abstract
The aim of this study was to evaluate the impact of different file sizes on the
accuracy of two electronic apex locators (EALs). Thirty extracted human sin-
gle-rooted permanent mandibular incisors were used. A #10 K-file was
inserted in the root canal until its end could be observed (using a light micro-
scope) through the apical foramen. One millimetre was subtracted to establish
working length (WL). Electronic readings were performed using MiniApex
Locator or Root ZX II, from #10 K-file to #130 K-file. Statistical analysis was
performed by two-way ANOVA and Tukey test (P ≤ 0.05). From #60 to #130 K-
file, observed differences were noted between the values obtained with both
EALs and WL (P ≤ 0.05). The MiniApex Locator showed increased means
when measurements were made with #50 to #70 and with #120 (P = 0.008)
and #130 (P = 0.005) K-files. File sizes influenced the accuracy of EALs – the
greater the instrumentation size, the higher mean differences compared to WL.

EALs reduces patient exposure to ionising radiation by

Introduction
Failure in determining the correct working length (WL)
may result in overfilling or underfilling and has the
potential for endodontic failure following a 10-year
observation period ranging from 10% to 50% (1). Accu-
rate determination of WL is a crucial part of successful
root canal therapy (2,3). Radiography is one of the most
traditional methods to determine WL (4); however,
radiographs may be distorted and/or magnified with sub-
sequent interpretation variability. Electronic apex loca-
tors (EALs) therefore have been used to improve the
accuracy estimation of the WL when compared to radio-
graphs (5,6).
Custer (7), in 1918, was the first to propose the use of
electronic devices to determine WL. In recent years,
many different models of EALs have been developed,
measuring the impedance with different frequencies
between the file tip and fluid within the canal (8,9),
including the MiniApex Locator (SybronEndo, Sybron
Dental, Anaheim, CA, USA) and the Root Zx II (J. Morita
MFG Corp., Kyoto, Japan). Current EALs are reliable,
exhibit high accuracy and reproducibility in locating the
major apical foramen (10,11). Additionally, the use of
reducing the number of radiographs to determine the
WL.
Despite this, the precision of electronic working length
measurement depends on the device used, the type of
irrigant and root canal anatomy variabilities (12–14). It
has been reported a large apical size can affect the varia-
tion in impedance values (9), especially seen in open
apex cases, apical resorption as well as following over-
instrumentation. It has also been demonstrated that
capacity for electrical isolation of the root canal decreases
in the apical third, as dentine tissue becomes less dense,
possibly impacting on accuracy (15). Furthermore, Ebra-
him et al. (16) observed an accuracy reduction of elec-
tronic measurements performed with different size files
in teeth with various foramen diameters. Therefore, the
aim of the present study was to evaluate the influence of
different size files on the accuracy of two electronic apex
locators, the MiniApex Locator and the Root Zx II.
Materials and methods
The research protocol was independently reviewed, and
approved by the Ethics in Research Committee of Bauru

© 2017 Australian Society of Endodontology Inc 1

Accuracy of Two Electronic Apex Locators
Dental School (132/2009). In the present study, 30 sin-
gle-rooted extracted permanent mandibular incisors,
with intact and completely formed roots, were used.
Teeth were washed with water and stored in saline
solution for one day. With a digital calliper (MTI Corpo-
ration, Tokyo, Japan), the thickness of the roots was
measured in the mesiodistal direction and 4.0 mm to
1.0 mm from the foramen. To measure the actual tooth
length, a coronal reference plane was first prepared by
levelling the incisal margin perpendicular to the long axis
of the tooth. A #10 K-file (Dentsply/Maillefer, Ballaigues,
Switzerland), fitted with a silicone stopper, was then
inserted into the root canal and moved apically until its
tip was visualised through the apical foramen using an
operating microscope (D.F. Vasconcellos, S~ao Paulo, SP,
Brazil) at 97.8 magnification. When the file tip was
observed, the silicone stopper was stabilised at the coro-
nal reference plane, the file was carefully removed from
the root canal and the distance between the silicone stop-
per and the tip of the measuring file was determined
using a digital calliper (MTI Corporation, Tokyo, Japan).
One millimetre was subtracted from this measurement
for establishment of the WL. Enlargement of the root
canal was initially performed using Gates Glidden drills,
in decreasing order, from #5 to #1, up to 3.0 mm short of
the working length.
Electronic root canal length measurements were per-
formed with the MiniApex Locator or Root ZX II using an
experimental model with alginate (Jeltrate, Dentsply
Industria e Comercio Ltda, Petropolis, Brazil), simulating
the periodontal ligament (15). Alginate was placed in
plastic cylindrical tubes measuring 30 mm in height and
30 mm in diameter. Two orifices were made in the tube
lids, one in the centre for placing the tooth, and the other
laterally for placing the lip electrode of the electronic
apex locator. The teeth were placed in the embedding
medium to their coronal reference plane (17).
Instrumentation of the root canal was performed with
a crown-down technique, to the pre-determined WL,
and irrigation with 1 mL of 1% sodium hypochlorite
(Biodin^amica Quımica e Farmac^eutica Ltda., Ibipor~ a,
Brazil) with each instrument change. Measurements,
with a #10 K-file, were established with Root ZX II and
MiniApex Locator and the canals were prepared to a
#130 K-file. Measurements were performed with all files
as well as with a #10 K-file, according to the manufac-
turer’s instructions. Measurements obtained with the
EALs were recorded by a single, calibrated operator. For
each instrument, three measurements were taken with
both electronic apex locators. Data were recorded and
statistical analysis performed by two-way analysis of
variance (ANOVA) and Tukey test, at a significance level
of 5%.
2 © 2017 Australian Society of Endodontology Inc
F. A. Orosco et al.
Results
There was no statistically significant difference between
the electronic readings and actual working length (WL)
until instrumentation with a #40 K-file (P > 0.05); Root
ZX II exhibited readings similar to WL until the #55
K-file. From the #60 to the #130 K-file, differences were
observed between the values obtained with both EALs
and WL (P ≤ 0.05). The MiniApex Locator showed
increased means when measurements were made with
the #50 to #70 K-files and with the #120 (P = 0.008) and
#130 (P = 0.005) K-files, in comparison to readings
obtained with Root ZX II (Figure 1).
Discussion
Electronic measurements of working length may be
influenced by different factors (12–14). Apex locators are
frequently used with smaller size files, however, the
effect of file size on measurement accuracy are not clear.
Therefore, the present study evaluated the influence of
different size files on the accuracy of two electronic apex
locators.
Embedding medium should have electroconductive
properties, surround the root apex and maintain close
contact with it in order to reproduce, as reliably as possi-
ble, clinical periapical conditions (18,19). The present
methodology used was performed in accordance with
previous studies suggesting alginate as a tooth embedding
medium of choice for in vitro studies with EALs, as it pro-
vides readings consistent with actual root canal lengths
(17–19). Alginate has been shown to be more accurate
than other media, as a colloidal gel, to meet the require-
ments of electroconductivity and contact with the root
(18,19). Duran-Sindreu et al. (20) did not find differences
Figure 1 Differences of the values (in mm) obtained with the electronic
apex locators and actual working length (WL). *Indicates statistical sig-
nificant differences among values of MiniApex, Root ZX II and actual WL
(P ≤ 0.05).
F. A. Orosco et al.
between the results obtained with the in vivo model and
those obtained with the in vitro model using alginate.
These findings support the use of in vitro models in the
evaluation of EALs.
To determine the actual length of the root canal, a
#10 K-file, fitted with a silicone stopper, was introduced
into the canal until its tip could be seen at the foramen,
with the aid of a microscope (21,22). The use of the
microscope made it possible to determine the end of the
file with the level of the foramen, making it easier to
observe the actual root canal length. Enlargement of the
root canal was initially performed using Gates Glidden
burs, creating a glide path allowing the file to reach the
apical foramen easily and directly, ensuring accuracy of
the EAL readings (23–25). Sodium hypochlorite was used
as the irrigant of choice as it has been found to not influ-
ence the accuracy of EALs (12,13).
The MiniApex Locator and Root ZX II were used in this
study as both have a high reliability index in readings
(14,17,26). These types of EALs operate by measuring
the impedance difference between high and low frequen-
cies of alternating electric current. As a result of this dif-
ference of frequency thresholds, the internal circuit of
these EALs can establish a quotient between the impe-
dances without being influenced by the presence of liq-
uid in the root canals. Thus, the electronic readings
remain stable until the tip of the file being inserted in the
root canal approaches the periapical tissues (27).
Our results showed that differences between the actual
working length and the measurements obtained with the
EALs occurred from a #55 K-File with the MiniApex
Locator and from a #70 K-File for Root ZX II. These
results are in agreement with a previous study, which
demonstrated that electronic measurements with differ-
ent size files influenced the accuracy of EALs, including
Root ZX II (16). This finding may, in part, be explained
by large size files reducing root canal wall thickness dur-
ing instrumentation, thereby decreasing the impedance
(15). In this study, differences between readings obtained
with Root ZX II and actual WL values decreased in com-
parison to measurements with the MiniApex Locator. It
is well documented that the Root ZX II has a greater
accuracy when compared to other EALs (4,16).
The findings of the present study clearly show that
electronic readings performed with the MiniApex Locator
and the Root ZX II are influenced by different size files as
the greater the instrumentation size, the higher mean dif-
ferences compared to actual working length.
Author contributions
I confirm that all authors have contributed significantly
and are in agreement with the manuscript.
© 2017 Australian Society of Endodontology Inc
Accuracy of Two Electronic Apex Locators
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