A comparative clinical evaluation of accuracy of six apex l...

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A comparative clinical evaluation of accuracy of six apex locators with intraoral periapical
radiograph in multirooted teeth: An in vivo study
Prahlad A. Saraf, P. Ratnakar, [...], and Sneha S. Vanaki

Abstract

Aim:
The purpose of this clinical study was to compare and clinically, to evaluate the accuracy of six apex locators with intra oral
periapical (IOPA) radiograph in multirooted teeth.

Materials and Methods:

A total of 90 multirooted teeth (maxillary and mandibular molars) with irreversible, infected or necrotic pulp tissue and
completely formed roots were included in this study and were divided randomly into six groups (Root ZX II, Raypex 6, I-Root,
Romiapex A-15, Sybron Endo Mini and Root ZX mini). The working length was determined using six different apex locators,
and the accuracy of the apex locators was compared with IOPA radiographs, to be categorized as accurate, short, and long or
beyond.

Results:
A total of 270 canals were evaluated, of which 233 (86.3%) canals exhibited acceptable working length, 28 (10.4%) canals
exhibited short working length, and only 9 (3.3%) canals exhibited working length beyond the apex. There were a statistically
significant results in all the groups (P < 0.05) and the comparison between the groups was statistically insignificant.

Conclusion:
The repeatability with that of apex locators is of great advantage, but the information gained from the radiographs cannot be
obtained by any other means. Therefore, it is recommended that radiograph and apex locators are the best combinations in
accurately determining the working length and the successful endodontics.

Key words: Apex locators, intraoral periapical radiographs, multirooted teeth, radiographic apex, working length

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INTRODUCTION
The removal of infected pulp tissue, necrotic material, and microorganisms from the root canal system is essential for endodontic
treatment success. This can be achieved only if the length of the root canal is determined accurately.[1]

Working length is defined as the distance from a coronal reference point to the point at which canal preparation and filling
should terminate.[2] A correct working length is a critical factor for the endodontic success. Failure to determine the proper root
canal working length during root canal treatment may compromise the treatment result.[3] To determine the working length, a
number of techniques, including tactile sensation, radiographs, and electronic apex locators are routinely used in clinics.[4]

Conventionally, conventional radiographs used to determine the working length which provides information about the canal
anatomy and surrounding tissues.[5] Radiographs are advantageous as the information they furnish, cannot be obtained from any
other source and its value is not diminished by a critical appraisal of its limitations.[6] However, the accurate determination of
root canal length radiographically is hindered due to anatomical variations, interference of anatomical structures, or errors in
projection.[7] Super imposition, anatomy interferences, distortion, shortening and elongation, interpretation variability, and lack
of three-dimensional representation affect the correct interpretation of the images.[2,5]

These factors have stimulated the development of electronic root length measuring devices (apex locators), which accurately
report the foramen or more precisely an area between the minor and major foramen diameter.[7]

Numerous electronic apex locating devices have been introduced since the 1960s. In 1962, Sunada demonstrated that the
electrical resistance between the periodontal ligament and oral mucosa has a constant value that can be measured. As a result,
some devices were developed for use as clinical aids in apex location. However, many devices often performed unpredictably
from patient to patient.[8]

The ROOT ZX (J. Morita Corp., Kyoto, Japan) has a high level of precision because of the introduction of the ratio method and
the subsequent development of the self-calibration. Root ZX II which works with the same principle of the original Root ZX,
which has been subjected to several studies showing a high level of reliability. Blood, electrolytes or other substances do not
impair its reliability.[3]

Root ZX mini also works according to the proven ratio technique as that of Root ZX and Root ZX II. This involves measuring
the impedances of two frequencies (400 Hz and 8 kHz) to provide an absolutely precise length measurement.

Creation of a steady algorithm for adapting the method for measuring the working length of the root canal depending on the
canal's moisture characteristic has been implemented in the apex locator of the so-called “sixth generation”– the adaptive type
RAYPEX-6.[9]

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I-Root (S-Denti, Seoul, Korea) I-Root was developed and upgraded based on the technology of e-Magic finderapex locator
which operates on dual frequency ratio based method.[10]

Romiapex A-15 (Romidan Ltd, Kiryat Ono, Israel) measure the working length by calculating the mean square root values of the
impedance at two different frequencies (0.5 and 8.0 kHz), measured separately. The device compares the results obtained with
reference values positions. Thus, the RomiApex A-15 operate by detecting the energy of the signal, rather than its amplitude.[11]

Sybron Endo's Mini Apex Locator, according to the manufacturers, despite its compact size, is rugged and durable. It uses a
sophisticated, multifrequency measurement system, an all-digital signal and an 80% shorter cable than other apex locators. The
manufacturer claims that this all adds up to increased signal integrity, easy operation, and consistently reliable measurements.[3]

Electronic apex locators reduce the number of radiographs required and are recommended to complement and assist radiographic
methods of working length determination.[12] Radiographic verification of electronic working length (EWL) is essential because
in some clinical situations apex locators give incorrect readings.[13] To achieve the highest degree of accuracy in working length
determination, a combination of several methods should be used.[14,15]

The information regarding their accuracy in root canal length determination in multirooted teeth is limited. Therefore, the
purpose of this clinical study was to compare and clinically evaluate the accuracy of six apex locators with intraoral periapical
(IOPA) radiograph in multirooted teeth.

MATERIALS AND METHODS

The study was conducted in the Department of Conservative Dentistry and Endodontics. Ethical clearance was obtained from the
Institutional Ethical Committee. Informed consent of each patient was obtained after explaining the clinical procedure.

Ninety multirooted teeth (maxillary and mandibular molars) with irreversible, infected or necrotic pulp tissue and completely
formed roots were included in the study. Patients using cardiac pace makers, who had a contributory medical history and the
teeth with no apical patency, radiographic evidence of resorption and bone loss were excluded from the study.

Tooth was anesthetized and isolated with a rubber dam. Endodontic access cavity was made, and a straight-line access to the root
canals was achieved. The orifices of the root canals were irrigated with sodium hypochlorite solution and excess was removed
from the pulp chamber by using cotton pellets. No attempt was made to clean debris or pulp tissue remnants before introducing
K file.

Following the preparation of adequate access cavity, apex locator was used to determine the EWL.

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Maxillary and mandibular multirooted teeth were randomly allocated to following study Groups. Group I: Working length
determined with ROOT ZX II apex locator, Group II: Working length determined with Root ZX mini apex locator, Group III:
Working length determined with the RAYPEX-6apex locator. Group IV: Working length determined with I-Root apex locator.
Group V: Working length determined with Romiapex-A15 apex locator. Group VI: Working length determined with Sybron
Endo mini apex locator.

Electronic measurements were made with instrument size selected according to the canal and the new file with firm silicone
rubber stopper for every canal was used which was advanced till the apex locator indicated the apex or apical constriction has
reached. The rubber stopper was set to the reference point when there was a stable reading for at least 5 s. The values were
recorded with the file in the canal. Working length radiograph was taken using bisecting angle technique. Based on the position
of the file tip to the radiographic apex on the IOPA radiograph, the samples were categorized using the following scoring criteria.
[16]

• Acceptable = 0–1 short

• Short = >1 mm short
• Long/Beyond = Beyond the apex

The data were analyzed statistically using Fisher's exact test with SPSS software version 19.00 (IBM Corp, Armonk, NY, USA).

RESULTS
A total of 90 teeth with 270 canals were evaluated in this study. Based on the scoring criteria, out of 270 canals 233 canals
exhibited acceptable working length, 28 canals exhibited short working length, and only 9 canals exhibited working length
beyond the apex [Table 1 and Figure 1].

Table 1
Accuracy of six different apex locators

Figure 1
Accuracy of six different apex locators

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ROOT ZX II had an accuracy of 97.8%, RAYPEX-6 had an accuracy of 95.6%, Romiapex had an accuracy of 95.6%, I-Root had
an accuracy of 93.3%, Sybron Endo Mini had an accuracy of 73.3%, and Root ZX Mini had an accuracy of 62.2%, respectively.
There were a statistically significant results in all the groups (P < 0.05) and the comparison between the groups was statistically
insignificant [Table 2 and Figure 1].

Table 2
Arch wise comparison of each apex locators

The archwise comparison, made between the maxillary and mandibular multirooted teeth was statistically insignificant,
indicating the position of the teeth did not affect the determination of the working length Table 2.

DISCUSSION
Apex locators have advantages over radiographic methods; EWL determination with apex locators is easier, faster and can be
indefinitely repeated without exposure to radiation. Moreover, modern apex locators can locate not only the apical foramen but
also, in contrast to radiographic methods, the apical constriction, which is an optimal endpoint for root canal preparation and
filling. The accuracy of apex locators is higher when compared with that of the radiographic methods.[13]

Nevertheless, it has been shown that a higher accuracy can be reached when both radiographic and EWL determination is
performed. A working length radiograph after EWL determination can reduce over-instrumentation and provide valuable
diagnostic information. Radiographic verification of the EWL is essential because in some clinical situations apex locators give
incorrect readings.[13]

The method used in the present study accurately simulates the clinical condition, unlike previous works in which the treated teeth
were later extracted, and the position of the file tip was then exposed.[17] The method used in this study enabled a
straightforward examination of the new electronic apex locator with conventional IOPA radiograph.

Multirooted teeth were selected for the study because the degree of apical foramen deviation is more in posterior teeth. It has also
been reported that as the curvature of the apical part of the root increases, the chances for erroneous radiographic working length

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also increased. Palatal and mesiobuccal roots of maxillary molars were associated with the highest incidence of inaccurate
radiographic working length compared with other roots in vitro and in vivo.[16]

A conventional IOPA radiograph was used to evaluate the accuracy as a direct measurement on the radiographs has proven to be
very accurate. This direct method was advocated on the premise that distortion and calculation errors are small enough to be of
no practical consequence.[18] An in vitro comparison of conventional and digital images showed that digital images resulted in
an overestimation of the actual file length by 2.81%–7.58%, whereas the same value for conventional images was only 1.13%.
[16] A radiograph is the only universally accepted, available and meaningful method of length adequacy assessment in the clinic.
[5]

Working length radiograph was taken using bisecting angle technique as it is the most common radiographic technique and the
presence of a rubber dam, rubber dam clamp, and the root canal instruments may complicate by impairing proper receptor
positioning and aiming cylinder angulations with paralleling technique.[19] The radiographic working length produced by both
paralleling and bisecting angle technique has been compared and concluded that comparable working lengths and the slightly
better performance of the former would be clinically irrelevant.[17]

The performance of electronic apex locators has conventionally been afforded some latitude of acceptable error in locating the
apex. An error tolerance of +/-1.0 mm is deemed clinically acceptable.[8] In the present study, we have determined a clinical
tolerance of 0-1 mm of the radiographic apex as the acceptable range.

The in vivo accuracy of apex locators ranges from a low of 15% to a high of 93.4% and as such cannot be relied on the sole
mechanism for working length location. Contemporary units have degrees of accuracy that range from 83% to 93.4%. Hence, to
achieve consistent success with this approach to working length determination, the astute clinician will integrate the use of
instruments with high quality, standardized diagnostic radiographs.[20]

In the present study, accuracy of 97.8% was obtained using Root ZX II which is in accordance with the in vitro study producing
values to a precision of 97.37%.[3] The accuracy of Raypex 6 is 95.6% which is in accordance with study conducted by Aydin et
al. with an accuracy of 88.2%.[4] The accuracy obtained with Sybron Endo Mini apex locator was 73.3% which was comparable
with that of the study conducted by Vasconcelos et al. in which the accuracy was 73.5%.[11] The accuracy attained with Root
ZX mini was 62.2% which is in accordance with that of the study conducted by da Silva et al. with an accuracy of 56.2%.[21]
According to the in vitro study by Sakkir et al. there is no statistically significant difference between I-Root and Root ZX II,
which correlates with the present study wherein the accuracy obtained is 93.3% which is comparable with that of Root ZX II.[10]
The accuracy of Romiapex A-15 was 95.6% which is in accordance with the study comparing the accuracy of Root ZX II and
Romiapex A-15 by Filho et al.[22]

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In the present study, the accuracy of Root ZX mini and Sybron Endo mini was inferior when compared to other apex locators.
Determination of apical constriction, associated with complete disruption of apical constriction, the shape of root canals and their
configuration varies with different apex locators. This may be the reason for inaccurate readings with respect to Root ZX mini
and Sybron Endo mini apex locators. Furthermore, electroconductivity of the dentine walls, the presence of apical ramifications
may also influence the accuracy of EALs.[4]

CONCLUSION
Root canal procedures should be limited within the confines of the root canal, with the logical endpoint for preparation and
obturation being the narrowest part of the canal. Therefore, it is necessary to apply a rational thought in combining radiography
and electronic devices to arrive at the desired apical terminus of the endodontic preparation and achieve the highest degree of
accuracy in working length determination.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.

Article information
J Conserv Dent. 2017 Jul-Aug; 20(4): 264–268.
doi: 10.4103/JCD.JCD_131_17
PMCID: PMC5721510
PMID: 29259365

Prahlad A. Saraf, P. Ratnakar,1 Thimmanagowda N. Patil, Raghavendra Penukonda, Laxmikant Kamatagi, and Sneha S. Vanaki

Department of Conservative Dentistry and Endodontics, PMNM Dental College and Hospital, Bagalkot, Karnataka, India
1Department of Conservative Dentistry and Endodontics, H. K. E. Society's S. N Institute of Dental Science and Research, Gulbarga, Karnataka, India
Address for correspondence: Dr. Prahlad A. Saraf, Department of Conservative Dentistry and Endodontics, PMNM Dental College and Hospital,
Bagalkot, Karnataka, India. E-mail: drprahladsaraf@gmail.com

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Received 2017 Apr 8; Revised 2017 Nov 2; Accepted 2017 Nov 7.

Copyright : © 2017 Journal of Conservative Dentistry

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the
identical terms.

This article has been cited by other articles in PMC.

Articles from Journal of Conservative Dentistry : JCD are provided here courtesy of Wolters Kluwer -- Medknow Publications

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