doi:10.1111/iej.
12140
Accuracy of working length measurement:
electronic apex locator versus cone-beam
computed tomography

pez1, J. A. Mart
ın2, V. Robles1 & M. P. Gonza
C. Lucena1, J. M. Lo
1
Department of Conservative Dentistry, School of Dentistry, University of Granada, Granada; and 2Private Practice, M

Spain
Abstract

pez JM, Mart
ın JA, Robles V, Gonza
Lucena C, Lo
lez-
Rodr
ıguez MP. Accuracy of working length measurement:
electronic apex locator versus cone-beam computed tomography.
International Endodontic Journal, 47, 246–256, 2014.
Aim To compare the accuracy of working length (WL)
determination using the Raypex 6® electronic apex
locator and cone-beam computed tomography (CBCT).
Methodology A total of 150 extracted human teeth
were decoronated and randomly assigned to five groups
(n = 30). WL was measured with the Raypex 6® at both
the ‘constriction’ and the ‘apex’ marks under dry condi-
tions (group 1) or with 2.5% NaOCl, distilled water or
Ultracain® (groups 2–4). The radiological WL (group 5)
was calculated from bucco-lingual and mesio-distal CBCT
sections. Differences between electronic, CBCT measure-
ments and actual length (AL) were calculated. Positive
and negative values, respectively, indicate measurements
falling short or long of AL. Two-way ANOVA and the
Bonferroni and Welch tests were used to compare mean
differences amongst groups. The chi-squared and Fisher’s
exact tests were used to compare percentages of precise,
0.5 and 1.0 mm of the AL measurements amongst
the experimental groups. Statistical analysis was per-
formed at a = 0.05.
Introduction
The accurate determination of working length (WL)
has a major impact on the outcome of root canal
Correspondence: Cristina Lucena, Facultad de Odontolog
ıa,
University of Granada, Campus de Cartuja Colegio M
aximo
s/n., E-18071 Granada, Spain (e-mail: clucena@ugr.es).
246 International Endodontic Journal, 47, 246–256, 2014

lez-Rodr
ıguez1
alaga,
Results Mean differences with respect to AL ranged
from 0.26 to 0.36 mm and from 0.05 to 0.18 mm,
respectively, for the electronic measurements at the
‘constriction’ mark and ‘apex’ mark. CBCT measure-
ments were an average of 0.59 mm shorter than AL.
Percentages of electronic measurements falling within
0.5 mm of the corresponding AL referred to the
‘apex’ mark were greater than at the ‘constriction’
mark, but the differences were only significant in
group 4 (with Ultracain®). Percentages of CBCT mea-
surements falling within 0.5 mm of AL (46.7%)
were significantly lower than electronic measure-
ments, regardless of the condition of the root canal.
In 30–38.5% of the measurements taken at the ‘apex’
mark and in 3.4–13.3% of those at the ‘constriction’
mark, the file tip extended beyond the foramen.
Conclusions Electronic measurements were more
reliable than CBCT scans for WL determination. The
Raypex 6® was more accurate in locating the major
foramen than the apical constriction under the exper-
imental set-up.
Keywords: apex locator, cone-beam computed
tomography scans, endodontics, irrigating solution,
root canal length determination.
Received 20 February 2013; accepted 19 May 2013
treatment (Seltzer et al. 1963, Ricucci 1998, Ricucci
& Langeland 1998) – the apical constriction (AC)
being the recommended end-point for canal prepara-
tion by several authors (Kuttler 1955, Ricucci &
Langeland 1998, Gordon & Chandler 2004).
Periapical radiographs and electronic apex locators
(EALs) are usually used for determining WL. Limita-
tions of conventional radiography include the sensi-
tivity of the technique, subjectivity and errors due to
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

image magnification, distortions or the superposition-
ing of anatomical structures (Real et al. 2011).
Moreover, because the AC cannot be detected radio-
graphically, the radiographic WL is actually an
estimation based on the average distance between the
constriction and the major foramen. Thus, WL is
often measured 0.5–1 mm short of the radiographic
apex. Nevertheless, the major foramen does not
always coincide with the anatomical apex, but may
be located laterally (Kuttler 1955, Dummer et al.
1984, ElAyouti et al. 2002) and at a distance of up
to 3 mm from the anatomical apex (Green 1955,
Dummer et al. 1984). The above reasons could
explain the common overestimation of radiographic
WL (ElAyouti et al. 2001, Williams et al. 2006).
Cone-beam computed tomography (CBCT) is a con-
temporary radiological imaging system that produces
undistorted images with a significantly lower-effective
radiation dose than conventional computed tomogra-
phy (CT) (Durack & Patel 2012). The CBCT images of
the area of interest can be displayed in mesio-distal,
bucco-lingual or coronal planes or simultaneously in
the three orthogonal planes, affording the clinician a
three-dimensional view of the area of interest (Patel
2009). This improved visualization of root canal
morphology could increase the accuracy of WL
measurements (Jeger et al. 2012). In fact, previous
studies have determined WL from pre-existing CBCT
scans, with results comparable to those afforded by
EALs (Janner et al. 2011, Jeger et al. 2012). However,
more studies are needed to validate the accuracy of
the WL measurements when using CBCT images by
comparing them with actual root canal length.
The accuracy of the latest generation EALs varies
over a wide range (45–97.6%), depending on the
device, the acceptable error range (0.5 mm or
1 mm) used and the mark (‘constriction’ or ‘apex’)
chosen by the operator for readings (Haffner et al.
2005, Goldberg et al. 2008, Cianconi et al. 2010,
Stoll et al. 2010). Many authors (Erdemir et al. 2007,
ober et al. 2011, Gomes et al. 2012) have used the
St€
‘0.5’ mark, because it theoretically indicates that the
tip of the file is at the AC. Conversely, it has been
suggested (Gulabivala & Stock 2004) that EALs
should be used with reference to the ‘apex’ mark,
because the impedance characteristics given for the
canal coronal to the apical foramen cannot be cali-
brated accurately. However, studies that have evalu-
ated the accuracy of measurements referred to both
apical references (i.e. ‘constriction’ and ‘apex’) are
scarce (Jung et al. 2011). The question therefore
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Lucena et al. Accuracy of EAL and CBCT
remains of whether WL should be established at the
point where the EAL indicates the constriction or at a
certain distance coronal to the foramen signal (Tsel-
nik et al. 2005).
The Raypex 6® (VDW, Munich, Germany) is a new
multifrequency EAL with a reliability that has not yet
been established. The present laboratory study
involves the following objectives:
• Evaluation of the accuracy of the Raypex 6® in
locating both the apical constriction and the major
foramen.
• Comparison of the accuracy of the Raypex 6®
under dry conditions and in the presence of differ-
ent irrigating solutions (2.5% NaOCl, distilled
water and Ultracain®).
• Assessment of the accuracy of WL measured from
CBCT images.
Materials and methods
The experimental protocol was approved by the Ethics
Committee of the University of Granada (Spain).
Patients who donated their teeth signed an informed
consent document prior to extraction.
A total of 150 human teeth (95 single- and 55
multirooted teeth), extracted for periodontal or ortho-
dontic reasons, were used. Teeth with immature
apexes, metallic restorations, fractures, root resorp-
tion, calcifications or previous endodontic treatments
as evidenced by radiographic examination were
excluded. The teeth were stored in 10% formalin solu-
tion for not longer than 2 weeks after extraction.
Once calculus and soft debris were removed, the teeth
were sectioned horizontally at the cement–enamel
junction to provide unrestricted access to the canal
and to obtain a flat surface. The crowns were marked
with a permanent marker to serve as reference for
the placement of the rubber stop. In each multirooted
tooth, one canal was randomly chosen for study.
Gates–Glidden drills (Dentsply Maillefer, Ballaigues,
Switzerland) of numbers 1 through 3 were used to
flare the coronal orifices. Canals were cleaned with
5 mL of saline solution and dried with paper points.
Then, the patency of the canal and major foramen
was checked with a size 10 K-Flexofile (Dentsply Ma-
illefer).
Electronic measurements
For the electronic measurements, the RayPex 6®
number series R6 2011090535 was used. A total of
International Endodontic Journal, 47, 246–256, 2014 247
 Accuracy of EAL and CBCT Lucena et al.

120 teeth were randomly assigned to four groups

(n = 30 each) according to the irrigating solutions
used:
Group 1: No irrigating solution (dry canals);
Group 2: 2.5% NaOCl;
Group 3: Distilled water (Milli-Q, Millipore Co.,
Billerica, MA, USA);
Group 4: Ultracain® (40/0.005 mg mL 1, Labora-
torios Normon S.A., Madrid, Spain).
The teeth were numbered and embedded in an
alginate model developed to test apex locators
(Lucena-Mart
ın et al. 2004). The Raypex 6® was used
according to the manufacturer’s instructions. Mea-
surements were taken with a standard size 10 or
15 K-Flexofile (Dentsply Maillefer), depending on the
width of the root canal, under dry conditions for sam-
ples belonging to group 1 and after irrigation of the
canal with 2 mL of the corresponding irrigant for
samples belonging to groups 2–4. Cotton tips were
used to eliminate excess irrigating solution and to dry
the tooth surface.
For measurements taken with the ‘constriction’
mark as reference, the file was advanced within the
root canal until the third green bar limit of the Ray-
pex 6® display was reached. In the case of measure-
ments taken with the ‘apex’ mark as reference, the
file was introduced to a point just beyond the major
foramen (red ball) and was then retracted slightly to Figure 1 The mould used for CBCT measurements was
the limit of the third yellow bar. In both cases, the placed upon a camera tripod.
measurements were considered to be valid when the
reading remained stable for at least 5 s. Unstable To standardize imaging, the working model was
measurements were not considered for statistical eval- placed in a reproducible position upon a camera
uation. The rubber stop was adjusted, and the dis- tripod (Fig. 1). A 36 s exposure time was established,
tance between it and the tip of the file was measured with a current amplitude of 8 mA and a voltage of
with digital calipers (Mitutoyo Corp., Tokyo, Japan). 84 kV. The data were reconstructed with 1.0-mm-
Measurements were recorded in millimetres. All teeth thick slices at an interval of 0.5 mm. The CBCT
were measured by a single operator experienced in images were obtained by an experienced radiology
the use of EALs. technician not involved in any step of the endodontic
measurements.
All CBCT measurements were performed by an
CBCT measurements
investigator well trained in CBCT diagnostic applica-
The remaining 30 teeth were used for the CBCT mea- tions. First, the root canal of each selected tooth was
surements (group 5). A model that simulated a lower placed in a vertical position to visualize, whenever
jaw was produced, using a model base (Dentalite, possible, the whole length of the canal in a single
Madrid, Spain) as mould; 15 teeth were included in slice. This procedure was repeated to obtain a bucco-
each mould using polyvinyl siloxane impression lingual (BL) and a mesio-distal (MD) section of all
material (Putty Soft Procl
ınic S.A., L′Hospitalet de teeth included. The measurement line was traced
Llobregat, Barcelona, Spain). from the reference occlusal plane following the cen-
The CBCT images were obtained with the Planme- tre of the canal to its terminus (Fig. 2). In the case
ca ProMax 3Ds (Planmeca, Helsinki, Finland), with a of curved canals, a multiple-line tracing tool was
basic voxel size of 0.5 mm and FOV 50 9 80 mm. used (Fig. 3), following each visible canal curvature

248 International Endodontic Journal, 47, 246–256, 2014 © 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 2 The measurement line was traced from the reference occlusal plane to the end of the canal.
Figure 3 The multiple-line tracing tool was used to measure curved canals.
in the respective CBCT slice (Jeger et al. 2012). The
arithmetic mean between the root canal length mea-
sured in the BL section and the MD section was
obtained and recorded as the CBCT WL. Apart from
reformatting procedures and saturation/contrast
adjustments, the images were not modified. The
alignment and measurement procedures for the
CBCT images described in this study were all per-
formed using specialized software (Planmeca Romexis
Viewer, Helsinki, Finland).
Actual length measurements
For the AL measurements, the specimens were removed
from their respective moulds and cleaned with water to
remove deposits. A third operator blinded to previous
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Lucena et al. Accuracy of EAL and CBCT
measurements inserted the same size K-Flexofile used
for the electronic measurement into each canal until
the tip became visible through the major foramen.
The file was then withdrawn until a magnifying glass
(92.5) showed its tip at the level of the most coronal
border of the major foramen (Fig. 4). The rubber stop
was adjusted to the occlusal reference, and the
distance from the stop to the file tip was measured
with the digital calipers. This measurement was
recorded as the actual length to major foramen
(ALMF).
To observe the apical constriction, a window 3 mm
in diameter was made in the apical portion of the root
using a diamond bur until the root canal became visi-
ble, followed by careful removal of the remaining tis-
sue with a size 12 scalpel blade (Bard Parker, Lincoln
International Endodontic Journal, 47, 246–256, 2014 249
 Accuracy of EAL and CBCT Lucena et al.
Figure 4 The tip of the file at the level of the most coronal
border of the major foramen.
(a)
(b)
Figure 5 (a) A window opened in the apical portion allows
visualize of the apical constriction. (b) The tip of the file
aligned with the apical constriction.
Park, NJ, USA), under a stereomicroscope (SZ-TP,
Olympus, Tokyo, Japan) (Fig. 5a). The corresponding
size 10 or 15 K-Flexofile was gently inserted into the
250 International Endodontic Journal, 47, 246–256, 2014
canal until the tip became aligned with the apical
constriction (Fig. 5b). The rubber stop was adjusted
to the occlusal reference, and the distance from the
stop to the tip of the instrument was measured and
recorded in mm as the actual length to apical con-
striction (ALAC).
Statistical methods
The sample size was estimated as 26 teeth per group
(a = 0.05, b = 0.05, with a minimum value for clini-
cal relevance of 0.5), but 30 teeth per group were
finally used to compensate potential losses of samples
during the study.
Data processing
Differences between electronic/CBCT measurements
and actual length (AL) were calculated. Negative and
positive values indicated measurements that respec-
tively fell long and short of the AL, whilst 0.0 indi-
cated coinciding measurements.
Data analysis
Two-way analysis of variance (ANOVA) was used to
identify possible significant interactions between the
mark (constriction/apex) of the EAL chosen for read-
ings and the condition (dry/NaOCl/distilled water/Ul-
tracain®) of the canal.
The Kolmogorov–Smirnov test revealed a normal
distribution, and the Bonferroni test was then used
for pairwise comparisons amongst groups of irrigating
solutions referred to the apical constriction (AC).
Likewise, one-way-ANOVA and the Welch test were
used to compare means amongst groups of irrigating
solutions and CBCT referred to the major foramen
(MF).
In addition, the differences between the electronic
or CBCT measurements and AL were classified into
three categories:
• Precise: Including those measurements coinciding
with the AL;
• 0.5 mm: Including those differences falling
within 0.5 mm of the AL;
• 1.0 mm: Including those differences falling
within 1.0 mm of the AL.
The chi-squared and Fisher’s exact tests were used
to compare percentages of precise, 0.5 mm and
1.0 mm measurements amongst the experimental
groups.
The statistical analysis was carried out accepting a
level of significance of 5%.
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Lucena et al. Accuracy of EAL and CBCT

tion’ mark ranged from 61.5% (when Ultracain® was

Results
Five teeth were excluded, because of unstable
measurements.
Two-way ANOVA showed a significant interaction
between the mark of the EAL chosen for readings
(constriction/apex) and condition of the root canal
(dry/NaOCl/distilled water/Ultracain®) (P < 0.001).
The means and standard deviations of the differ-
ences between the electronic or CBCT measurements
and AL are shown in Table 1.
When the ‘constriction’ mark was taken as refer-
ence, the mean differences obtained in the presence
of distilled water and Ultracain® were significantly
different from those obtained under dry conditions
or in the presence of 2.5% NaOCl (Table 1,
P < 0.001). Furthermore, electronic measurements
obtained in dry canals and with 2.5% NaOCl were
longer than the AL, whilst in the presence of dis-
tilled water and Ultracain®, the measurements were
shorter than the AL. When the ‘apex’ mark was
taken as reference, both electronic measurements
and measurements on CBCT scans tended to fall
short of AL. Nevertheless, no statistically significant
difference was found amongst the irrigating solutions
(P > 0.05).
The mean difference between the electronic
measurements taken with the ‘constriction’ mark as
reference and AL to the major foramen (ALMF)
ranged from 0.28 to 0.63 mm. The positive sign of
the mean in all the groups indicates that most of the
measurements fell short of the major foramen.
Table 2 shows the percentages of precise, 0.5 and
1.0 mm measurements obtained. Percentages of
0.5 mm electronic measurements to the ‘constric-
used as irrigant) to 76.7% (with NaOCl), but the
differences between groups were not statistically
significant. The percentage of 0.5 mm electronic
measurements to the ‘apex’ ranged from 79.3% (with
distilled water) to 100% (with Ultracain®), the differ-
ences between these two groups being statistically
significant (P = 0.043). Radiographic measurement of
WL in CBCT images (with only 46.7% of the measure-
ments within the error range of 0.5 mm) proved
less accurate than the electronic measurements,
regardless of the root canal contents (P < 0.05).
As seen in Table 2, the percentages of electronic
measurements taken with the ‘constriction’ mark as
reference and coinciding with AL to the major fora-
men ranged from 0 to 11.5%. Between 51.7% and
80% of the measurements fell within 0.5 mm to the
major foramen. Overall, a greater percentage of 0.5
and 1.0 mm measurements was obtained in the
electronic measurements with the ‘apex’ mark as ref-
erence than with the ‘constriction’ mark (Table 3),
although the difference only proved statistically signif-
icant within both precision ranges in the group in
which Ultracain® was used as irrigating solution.
Table 4 shows the frequency and percentages of
electronic or CBCT measurements that prove precise,
short and long with respect to actual length.
Discussion
Because there have been no previous studies on the
accuracy of the Raypex 6®, the primary objective of
this study was to determine which reference mark
(‘constriction’ or ‘apex’) affords a more exact determi-
nation of WL with this EAL and to establish whether

Table 1 Mean and standard deviations (mm) of differences between electronic or CBCT measurements and actual length

ALAC-ELC ALMF-ELF*/ALMF-CBCTL** ALMF-ELC

Group n Mean (SD) Max Min Mean (SD) Max Min Mean (SD) Max Min
a a a
1 30 0.36 (0.39) 1.32 0.72 0.12 (0.31) 0.64 0.82 0.31 (0.31) 0.24 1.05
2 30 0.31 (0.35)a 1.06 0.45 0.08 (0.24)a 0.34 0.98 0.28 (0.28)a 0.26 0.98
3 29 0.25 (0.63)b 0.79 2.62 0.18 (0.53)a 0.60 1.70 0.63 (0.59)b 0.40 2.90
4 26 0.26 (0.47)b 0.57 1.10 0.05 (0.28)a 0.50 0.50 0.47 (0.39)ab 0.30 1.20
5 30 0.59 (0.48)b 0.35 1.58

ALAC, actual length at apical constriction; ELC, electronic length at ‘constriction’ mark; ALMF, actual length at major foramen;
ELF, electronic length at ‘apex’ mark; CBCTL, root canal length measured on CBCT scans.
*Applicable in groups 1–4.
**Applicable in group 5.
Group 1, dry conditions; Group 2, 2.5% NaOCl; Group 3, distilled water; Group 4, Ultracainâ; Group 5, CBCT. Positive values indi-
cate smaller means than the AL. Negative values indicate greater means than the AL. Maximum, the largest measurement with
respect to AL. Minimum, the shortest measurement with respect to AL. Different small letters denote statistically significant differ-
ences between groups (P < 0.001).

© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 47, 246–256, 2014 251
 Accuracy of EAL and CBCT Lucena et al.

Table 2 Frequency (%) of measurements precise/0.5 mm tomical variability of the apical region, some authors
of the AL/1 mm of the AL take 1 mm to be the acceptable error range (Real
Group n Precise 0.5 mm 1 mm et al. 2011). However, 0.5 mm is the margin
regarded as acceptable by most authors. Three mea-
ALAC-ELC 1 30 2 (6.7)a 20 (66.7)a 29 (96.7)a
surements’ precision ranges (precise, 0.5 mm of the
2 30 0 (0)a 23 (76.7)a 28 (93.3)a
3 29 2 (6.9)a 20 (68.9)a 27 (93.1)a AL and 1.0 mm of the AL) were considered in the
4 26 1 (3.9)a 16 (61.5)a 24 (92.3)a present study. On the other hand, although the mini-
ALMF-ELF 1 30 0 (0)a 26 (86.7)ab 30 (100)a mum proportion of acceptable measurements required
2 30 2 (6.7)a 29 (96.7)ab 30 (100)a to define an EAL as precise has not been established
3 29 2 (6.9)a 23 (79.3)b 28 (96.5)ab
(Guise et al. 2010), it seems obvious that the greater
4 26 2 (7.7)a 26 (100)a 26 (100)a
5 30 0 (0)a 14 (46.7)c 24 (80.0)b the percentage of acceptable measurements, the
ALMF-ELC 1 30 0 (0)a 24 (80.0)a 29 (96.7)a greater the accuracy.
2 30 1 (3.3)a 24 (80.0)a 30 (100)a In this study, the third green bar limit of the
3 29 2 (6.9)a 15 (51.7)b 25 (86.2)b Raypex 6 display was considered to represent the apical
4 26 3 (11.5)a 17 (65.4)b 23 (88.5)b
constriction in accordance with a previous study (Ding
ALAC, actual length at apical constriction; ELC, electronic et al. 2010) that used this reference to detect the
length at ‘constriction’ mark; ALMF, actual length at major
apical constriction with the Raypex 5 EAL. However,
foramen; ELF, electronic length at ‘apex’ mark; Group 1, dry
conditions; Group 2, 2.5% NaOCl; Group 3, distilled water; the choice of another display reference could modify
Group 4, Ultracainâ; Group 5, CBCT; Precise, measurements the accuracy percentages of the electronic device.
coinciding with the actual length; 0.5 mm, measurements fall-
Therefore, each operator should correlate his or her
ing within 0.5 mm of the AL; 1.0 mm, measurements falling
within 1.0 mm of the AL. own radiographic and clinical findings with the ana-
Different smaller letters in columns denote statistically signifi- log dial readings on the instrument (Mayeda et al.
cant differences (P < 0.05) in percentage of measurements
1993).
within categories (ALAC-ELC/ALMF-ELF/ALMF-ELC) amongst
the experimental groups. In addition, as explained in the Materials and Meth-
ods and in coincidence with previous studies (Jenkins
the use of different irrigating solutions could signifi- et al. 2001, Azabal et al. 2004), determination of the
cantly affect the accuracy of the measurements actual working length at the major foramen was
obtained. In addition, the accuracy of the root canal made by observing the latter with a magnifying glass
measurements made from CBCT images with respect (92.5). However, because identification of the apical
to the AL of the canals was compared. constriction required higher magnification, a stereo-
Locator reliability is generally evaluated by calcu- microscope (920–25) was used. This methodological
lating the discrepancy between the electronic mea- difference may have implied less precision in the mea-
surements and the reference control length and/or by surements of the actual length to the major foramen.
calculating the percentage of acceptable measure- Taking into account the above limitations, in this
ments, that is, the number of measurements of the study, the Raypex 6® was able to precisely locate the
device that fall within an arbitrarily pre-established AC in only 5 (4.3%) of the 115 measurements made
error range. Taking into account the enormous ana- (Table 2). In 68.7% (79 of the 115) and 94% (108 of

Table 3 Frequency (%) of measurements precise/0.5 mm of the AL/1 mm of the AL: comparison between electronic mea-
surements referred to the ‘constriction’ mark versus the ‘apex’ mark

Precise 0.5 mm 1 mm

Group n ‘Constriction’ ‘Apex’ ‘Constriction’ ‘Apex’ ‘Constriction’ ‘Apex’

1 30 2 (6.7) 0 (0) 20 (66.7) 26 (86.7) 29 (96.7) 30 (100)

2 30 0 (0) 2 (6.7) 23 (76.7) 29 (96.7) 28 (93.3) 30 (100)
3 29 2 (6.9) 2 (6.9) 20 (68.9) 23 (79.3) 27 (93.1)* 28 (96.5)*
4 26 1 (3.9) 2 (7.7) 16 (61.5)* 26 (100)* 24 (92.3)* 26 (100)*

Precise, measurements coinciding with the corresponding actual length; 0.5 mm, measurements falling within 0.5 mm of the
corresponding AL; 1.0 mm, measurements falling within 1.0 mm of the corresponding AL; Group 1, dry conditions; Group 2,
2.5% NaOCl; Group 3, distilled water; Group 4, Ultracainâ.
*Denotes statistically significant differences between electronic measurements referred to the ‘constriction’ mark versus the ‘apex’
mark (P < 0.05).

252 International Endodontic Journal, 47, 246–256, 2014 © 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Lucena et al. Accuracy of EAL and CBCT

Table 4 Frequency (%) of electronic or CBCT measurements that prove precise, short and long with respect to actual length

Shorter than AL Shorter than AL Longer than AL Longer than AL

Group n (>0.5 mm) (≤0.5 mm) Precise (≤0.5 mm) (>0.5 mm)

ALAC-ELC 1 30 1 (3.3) 1 (3.3) 2 (6.7) 17 (56.6) 9 (30.0)

2 30 0 (0) 4 (13.3) 0 (0) 19 (63.3) 7 (23.3)
3 29 7 (24.1) 11 (37.9) 2 (6.9) 7 (24.1) 2 (6.9)
4 26 9 (34.6) 8 (30.7) 1 (3.9) 7 (26.9) 1 (3.9)
ALMF-ELF 1 30 3 (10.0) 18 (60.0) 0 (0) 8 (26.7) 1 (3.3)
2 30 1 (3.3) 17 (56.6) 2 (6.7) 10 (33.3) 0 (0)
3 29 5 (17.3) 13 (44.8) 2 (6.9) 8 (27.6) 1 (3.4)
4 26 0 (0) 14 (53.8) 2 (7.7) 10 (38.5) 0 (0)
5 30 15 (50.0) 13 (43.3) 0 (0) 2 (6.7) 0 (0)
ALMF-ELC 1 30 6 (20) 20 (66.7) 0 (0) 4 (13.3) 0 (0)
2 30 6 (20) 19 (63.3) 1 (3.3) 4 (13.3) 0 (0)
3 29 14 (48.3) 12 (41.4) 2 (6.9) 1 (3.4) 0 (0)
4 26 9 (34.6) 12 (46.2) 3 (11.5) 2 (7.7) 0 (0)

ALAC, actual length at apical constriction; ELC, electronic length at ‘constriction’ mark; ALMF, actual length at major foramen;
ELF, electronic length at ‘apex’ mark; Group 1, dry conditions; Group 2, 2.5% NaOCl; Group 3, distilled water; Group 4, Ultracainâ;
Group 5, CBCT; Shorter, measurements shorter than the actual length; Longer, measurements longer than the actual length.

the 115) of the measurements made, the margin of
error in locating AC was 0.5 and 1.0 mm, respec-
tively. Thus, when the display showed the ‘constric-
tion’ signal, the file tip was located an average of
between 0.26 mm coronal and 0.36 mm apical with
respect to the mentioned anatomical reference,
depending on the irrigating solution used (Table 1).
Specifically, under dry conditions and in NaOCl-irri-
gated canals, the Raypex 6® overestimated WL, whilst
in the presence of distilled water and Ultracain®, the
locator underestimated WL.
Erdemir et al. (2007) found that independent of the
irrigating solution used (0.9% saline, 2.5% NaOCl,
3% H2O2, 0.2% chlorhexidine, 17% EDTA, Ultracain®
or dry conditions), the Root ZX® underestimated WL
referred to the apical constriction; indeed, none of
their measurements exceeded that reference. How-
ever, these findings are in conflict with most of the
existing literature (Tselnik et al. 2005, Wrbas et al.
2007). In fact, it has been seen that when the elec-
tronic measurements are made at the ‘0.5’/’constric-
tion’ mark, the file tip is actually closer to the major
foramen than to the apical constriction. Specifically,
Wrbas et al. (2007), Ding et al. (2010), St€ ober et al.
(2011) and Gomes et al. (2012), using the Raypex 5®
(with 2.5–4% NaOCl or 0.9% sodium chloride) with
the AC as reference, obtained a mean distance
between the file tip and the major foramen of 0.15,
0.38, 0.17 and 0.22 mm, respectively. The present
data coincide with these results, because the mean
difference between the electronic measurements taken
with the ‘constriction’ mark as reference and AL to
the major foramen was 0.28  0.28 mm in canals
irrigated with 2.5% NaOCl and 0.31  0.31 mm in
dry canals (Table 1).
On the other hand, when the Raypex 6® was used
taking the ‘apex’ mark as reference, the file tip was
located precisely at the major foramen in only 6 (5.2%)
of the 115 measurements made. Nevertheless, in the
rest of the cases, the mean distance to the major fora-
men was minimal: 0.12  0.31 mm in dry canals and
0.08  0.24 mm in NaOCl-irrigated canals (Table 1).
These values are smaller than those registered by
Kaufman et al. (2002) (0.57  0.10 mm under dry
conditions and 0.34  0.10 mm with NaOCl for the
Root ZX® and 0.56  0.08 mm under dry conditions
and 0.33  0.08 mm with NaOCl for the Bingo
1020®), but coincide with those of Stoll et al. (2010)
(0.01  0.34 mm with the Dentaport ZX®,
®
0.38  0.42 mm with Element Diagnostic and
0.06  0.17 mm with the Raypex 5®). On the other
hand, in the present study neither the canal condition
(dry/irrigated) nor the type of irrigant significantly
influenced the magnitude of the discrepancy between
the electronic WL and AL to the major foramen.
The evaluation of these data and the percentages of
0.5 mm measurements referred to the constriction
(61.5–76.7%) and major foramen (79.3–100%)
indicate that the Raypex 6® detects the major fora-
men more consistently than the apical constriction.
This observation could be explained by the sudden
change in electric impedance produced when the file
is displaced from within the canal to the conducting
medium. In addition, the morphology of the apical
constriction can differ greatly from what may be
regarded as the ‘typical’ morphology; in effect, there

© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 47, 246–256, 2014 253
 Accuracy of EAL and CBCT Lucena et al.
may be several constrictions in one same canal, or
there even may be an extensive zone of parallel walls
(Dummer et al. 1984) – a situation that could affect
the accuracy of the locator. In this context, Herrera
et al. (2007) reported that Root ZX® precision varies
as a function of the apical constriction diameter.
Nevertheless, the above does not necessarily imply
that the ‘constriction’ mark cannot serve as a valid
reference for establishing the position of the major
foramen. It is also important to compare the repro-
ducibility of the measurements made with respect to
both references, this being indirectly evaluable from
the magnitude of the standard deviation (Lee et al.
2002). Table 1 shows that in proportion to the mag-
nitude of the mean, the standard deviation is greater
in the case of measurements made with respect to the
‘apex’ (ALMF-ELF) than in those referred to the ‘con-
striction’ mark (ALMF-ELC). According to Gomes et al.
(2012), if the readings are consistent (small standard
deviation), and if the mean distance between the file
tip and the apical mark is known, an accurate WL
can be obtained by subtracting or adding a pre-deter-
mined value from the device reading. Based on the
above, it was considered that although the ‘constric-
tion’ mark does not allow accurate location of the
AC, it does represent a valid reference for determining
the position of the major foramen.
On the other hand, from the data reported in
Table 4, the percentage of measurements that
exceeded the major foramen can be calculated. When
the locator was used in reference to the ‘apex’ signal,
this percentage ranged from 30% (group 1:
26.7% + 3.3%) to 38.5% (group 4: 38.5% + 0%),
depending on the irrigating solution. The percentage
of measurements exceeding the major foramen when
the Raypex 6 was used referred to the ‘constriction’
signal was considerably lower (3.4–13.3% depending
on the irrigant). In most of the measurements referred
to the ‘apex’ mark, the discrepancy was in the range
of 0.5 mm; however, because overestimation of the
WL worsens the prognosis of endodontic treatment, it
was considered relevant to take these data into
account.
Therefore, under the experimental conditions, the
Raypex 6® was reliable in detecting the major fora-
men when using either the ‘apex’ or the ‘constriction’
mark as reference. Furthermore, excluding the use of
the apex locator under dry conditions or with distilled
water as irrigant, the longest measurements with
respect to the ‘apex’ signal and with respect to the
‘constriction’ signal exceeded the major foramen by
254 International Endodontic Journal, 47, 246–256, 2014
0.5 mm (group 4) and 0.3 mm (group 4), respec-
tively (Table 1). Consequently, to avoid the risk of
overinstrumentation, 0.5 mm should be subtracted
from the Raypex 6® reading referred to the ‘apex’
mark or 0.3 mm referred to the ‘constriction’ mark.
However, because it is difficult to know precisely
the actual distance of the file tip with respect to the
foramen, this correction implies the risk of underesti-
mating the working length. In this experiment, the
shortest measurement in the readings referred to the
‘apex’ signal was 0.98 mm coronal to the major fora-
men (Table 1, group 2), whilst the shortest measure-
ment in the readings referred to the ‘constriction’
signal was 1.20 mm with respect to the major fora-
men (Table 1, group 4). Therefore, if the proposed
correction was applied under these conditions, the file
tip actually would have been located 1.48 mm (in
the former case) and 1.5 mm (in the latter case) coro-
nal with respect to the major foramen. In summary,
under the conditions of this experiment and applying
the proposed correction, the file tip would be located
between 0 mm and approximately 1.5 mm coronal to
the foramen in practically 100% of the cases
(Table 1).
In relation to the canal irrigant factor, although
electronic measurement of the working length in dry
canals or canals irrigated with distilled water is not
included amongst the specifications for using the Ray-
pex 6, due to the great variability in the actual condi-
tions of use of the locators in clinical practice, it was
considered opportune to include both experimental
groups. The results, in agreement with previous stud-
ies (Erdemir et al. 2007, Gomes et al. 2012), show
that electronic measurements in dry canals can be
performed with results similar to those obtained in
the presence of NaOCl or Ultracain®. On the other
hand, the use of distilled water as irrigant had a neg-
ative effect upon the precision of the Raypex 6® –
although significant differences in percentages of
0.5 mm measurements were only found between
the Ultracain® group and the distilled water group
when the locator was used in reference to the ‘apex’
signal (Table 2). This result was expected, given that
the conductivity of distilled water (which lacks many
ions such as chlorides, calcium, magnesium or fluo-
ride) can be almost zero (depending on the degree of
distillation).
Regarding the accuracy of the canal measurements
with CBCT, given the low percentage of measurements
within the error range of 0.5 mm obtained (46.7%)
and the magnitude of the discrepancy with respect to
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

AL, it must be concluded that its performance is infe-
rior to that of the Raypex 6®. However, the possibility
of contrasting this observation is limited, although two
previous studies (Janner et al. 2011, Jeger et al. 2012)
have used this radiological technique in determining
WL, both were in vivo studies, and they moreover used
the electronic reading obtained with an EAL (Root
ZX®) as control for the comparisons, instead of AL.
Thus, with due consideration of these methodologi-
cal differences, the mean discrepancy found in the
present study between the CBCT measurements and
the actual lengths (0.59 mm) was greater than those
registered by the above-mentioned authors (0.40 mm
according to Janner et al. (2011) and 0.51 mm in the
study published by Jeger et al. (2012)).
Sherrard et al. (2010) evaluated the accuracy and
reliability of tooth length and root length measure-
ments derived from CBCT volumetric data at 0.2, 0.3
and 0.4 mm voxel sizes. They found that the CBCT
measurements were not significantly different from
the actual lengths; however, the 0.4 mm CBCT scans
seemed to be associated with slightly lower reliability
than 0.3 and 0.2 mm voxel sizes. This would be
attributed to the difficulty in clearly identifying the
landmarks, because larger voxel sizes are associated
with decreased spatial resolution. Therefore, the voxel
size used in the present study (0.5 mm) could explain
the significant differences found between the CBCT
measurements and the actual lengths. In addition,
the studies of Janner et al. (2011) and Jeger et al.
(2012) were both in vivo studies. Also, CBCT scans
were made of fresh porcine heads in the study of
Sherrard et al. (2010). In the present study, the teeth
were embedded in a polyvinyl siloxane model, and
this could imply greater difficulty in clearly identifying
the landmark of the end of canal.
On the other hand, of the 53.3% of measurements
that were outside of 0.5 mm range of the AL, all
corresponded to underestimations of the canal length
(Table 4) – in contrast to the tendency towards over-
estimation that characterizes conventional radiogra-
phy (Stein & Corcoran 1992, ElAyouti et al. 2001).
Conclusions
Under the experimental conditions, the Raypex 6®
was more accurate than CBCT scans (at 0.5 mm
voxel size) for WL determination. The Raypex 6® was
more accurate in locating the major foramen than
the apical constriction. The position of the major fora-
men could be located with great accuracy using
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Lucena et al. Accuracy of EAL and CBCT
either of the reference marks (‘apex’ or ‘constriction’).
The use of this locator does not fully avoid the risk of
overestimating WL.
Acknowledgements
This research was supported by Ministerio de Ciencia e
Innovacion (Spain) grant MAT2009:09795.
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