ENDODONTOLOGY

Original Research - 2

A comparative evaluation of the accuracy of third

generation electronic apex locator (root zx) and
conventional radiography to determine working length
- An in vivo study
MANUEL S THOMAS *
SHASHIRASHMI ACHARYA **
KUNDABALA M ***

ABSTRACT
Aim: The purpose of this in vivo study was to compare the accuracy of a third generation electronic apex locator
(Root ZX) and conventional radiography in determining the working length.
Method: Twenty adult human teeth indicated for extraction were taken for the study. Endodontic access was
prepared, pulp extirpated, canals irrigated and the pulp space dried. Occlusal reference point was established. A
third generation electronic apex locator, Root ZX was used according to the manufactures instructions to measure
the working length. The working length was also measured by conventional radiography using Ingles method.
After extraction, No. 15 K file with rubber stop was introduced into the canal and advanced until the file tip was
visualized at the foramen using 3X magnification. The true canal length was measured for each tooth and the
measurements were read to the nearest 0.5 mm. The actual working length was then established by subtracting
0.5 mm from the true canal length.
Result: The mean of the working length determined was calculated. Mean of the working length obtained by Root
ZX (G1) and that obtained by conventional radiographic method (G2) was compared with the mean of the actual
working length (G3) by One sample T test. The results revealed no statistically significant difference between the
actual working length and the working length obtained by Root ZX and conventional radiography. Even though
Root ZX showed less deviation from the actual working length than the conventional radiographic
method, there was no significant difference between the actual working length, the working length obtained by
Root ZX and conventional radiography.
Conclusion: Working length determined using Root ZX showed lesser deviation from actual working length
compared to conventional radiographic method, even though there was no statistically significant difference
between the experimental groups.
Clinical significance: The third generation apex locators are reliable tool for the determination of the working
length, even though the use of intra oral radiography cannot be ignored. A technique that combines the use of
electronic devices and radiograph will certainly reduce the radiation exposure, since the adjustment of the lengths
of the file would be minimal.
Key words: Electronic apex locator, Root ZX, conventional radiography, Ingles technique, actual working length,
apical constriction.

* Assistant Professor, *** Professor and Head, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore - 575001. **
Professor and Head, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal-576104.

14

ENDODONTOLOGY

A COMPARATIVE EVALUATION OF THE ACCURACY OF THIRD GENERATION ELECTRONIC APEX LOCATOR (ROOT
ZX) AND CONVENTIONAL RADIOGRAPHY TO DETERMINE WORKING LENGTH AN IN VIVO STUDY

INTRODUCTION

the study. An informed written consent was obtained

Accurate working length determination helps

from each patient before the study was initiated. A

to decide the extent to which the instruments are

standard intra oral periapical radiograph was taken

placed and worked in the root canal system and

using paralleling technique to determine the

this will determine how effectively the unwanted

presence or absence of periapical pathosis, root

items are removed from it. This will also limit the

resorption or apical closure. After local anesthetic

depth to which the canal filling may be placed.

administration standard access opening was done.

Correct working length determination will also affect

The incisal edge of the anterior tooth was made

the degree of pain and discomfort that the patient

straight and for the posterior tooth, decuspation was

would feel following the appointment. Thus it plays

done using diamond bur (Diatech, Swiss Dental

an important role in determining the success of the

Instruments) for standardization of the reference

treatment.

point. The root canal orifices were enlarged by Gates

Glidden drill (Mani, Tochigi, Japan). The pulp was

According to Kuttler, the narrowest diameter

then extirpated with a barbed broach (Produitus

of the canal is definitely not at the site of exit of the

Dentaires, Vevey, Switzerland) and the canal

canal from the tooth, but usually occurs within the

thoroughly irrigated with 0.9% saline followed by

dentin, just prior to initial layer of cementum. This

which the pulp space was dried with sterile paper

was referred to as the minor diameter of the canal,

points (Diadent Group International Inc., Korea)

although others refer it to as the apical constriction.

The average distance between the minor and the

Root ZX (J. Morita Co., Tokyo and Japan) was

major diameter was 0.524 mm in teeth examined

used according to the manufacturers instructions. 3

in an 18 to 25 year old group and 0.659 mm in a

The clip was applied to the patients lip and no. 15

55 year old and older group. 2

K-file (Densply India Pvt. Ltd., India) connected to

the electrode of the device was apically advanced

Accepted techniques for the determination of

in the canal, until it reached the previously

the working length include tactile, radiographic and

calibrated 0.5 mm sign on the screen of the device,

electronic method. To achieve the highest degree

which is accepted as the apical constriction. At the

of accuracy in working length determination, a

meters 0.5 reading, the length of the file was

combination of several methods should be used.

measured and the value recorded.

The purpose of this study was to compare the

The radiographic method was made according

accuracy of the third generation apex locator (Root

to Ingles method.

ZX) and conventional radiography in determining

The file was introduced into

the canal till the tentative working length which was

the working length in-vivo.

obtained from the preoperative radiograph. Adult

MATERIALS AND METHODS

film (Kodak, E-speed film) was used in the study

A total of 20 adult human anterior teeth and

with an exposure time of 0.6 seconds. Paralleling

premolars indicated for extraction due to pathology

radiographic technique was followed (Rinn XCP,

or as a part of orthodontic treatment were taken for

Rinn Corporation, Elgin, Illinois). It produces

15

ENDODONTOLOGY

MANUEL S THOMAS, SHASHIRASHMI ACHARYA, KUNDABALA M

improved images as the result of, placing the film

indicated for extraction were measured using three

parallel with the long axis of the tooth with the

methods:

central X-ray beam directed at right angle to the

1. Group 1 (G1) Root ZX

tooth and film. This orientation minimizes geometric

2. Group 2 (G2) Conventional radiography

distortion. 5 The films were uniformly exposed and

3. Group 3 (G3) Actual working length

processed by hand. The films were developed for

30 seconds, followed by a 5 minute water wash

The mean of the working length in all the three

and fixed for 60 seconds. The measure of difference

groups were calculated (Table 1)

between the end of the instrument and the

radiographic apex is added to the original length.

G1 shows the mean value of 19.125 with

From the adjusted length of the tooth, 1.0 mm

standard deviation of 1.677

safety factor is subtracted to confirm to the apical

G2 shows the mean value of 18.725 with

termination of the root canal at the apical

standard deviation of 1.766

constriction.

G3 shows the mean value of 19.075 with

standard deviation of 1.632

After careful extraction of the teeth, they were

placed in 5.25% sodium hypochlorite solution

The mean value of G1 and G2 were compared

(Novo dental product, Mumbai) to remove any

to the actual working length using One Sample T

remnants of periodontal tissue from the apical

test, with test value kept as 19.075. The P value

portion of the root surface. The actual length of the

was set at 0.05 (Table 2 and Graph 1).

tooth was determined using the same reference

point and the same file used previously. The file

The P value for G1 and G2 were found to be

was placed into the canal until the tip was visualized

0.895 and 0.386 respectively, which is statistically

from a tangential angle at the apical exit using 3X

not significant.

magnification (Carl Zeiss, Germany). The stopper

The mean differences between the actual

was set at the occlusal reference point and the file

working length measurement and the measurements

removed and set aside. The true length was

in the other two groups were also calculated (Table

determined for each tooth using a millimeter scale.

1 and Graph 2). The mean deviation of working

Measurement was read to the nearest 0.5 mm. The

length determined by Root ZX from the actual

actual working length was established by subtracting

working length (+0.05) was less when compared

0.5 mm from the true canal length.

to that determined by the radiographic method (-

The working length readings recorded were

0.35). A positive value for mean difference indicated

tabulated and the values were subjected to statistical

that the tip of measuring instrument was beyond

analysis.

the actual working length and a negative value

indicated that instrument was short of the actual

RESULTS AND ANALYSIS

working length.

Working length in 20 adult human teeth

The frequency histogram (Table 3 and Graph

16

ENDODONTOLOGY

A COMPARATIVE EVALUATION OF THE ACCURACY OF THIRD GENERATION ELECTRONIC APEX LOCATOR (ROOT
ZX) AND CONVENTIONAL RADIOGRAPHY TO DETERMINE WORKING LENGTH AN IN VIVO STUDY

3) demonstrates that occurrence of deviation from

The results of the present study showed that

the actual working for G1 and G2. The most

there was no statistically significant difference

frequent response for the apex locator deviation

between the actual working length and working

was 0.0 (actual working length). Fourteen of the

length determined by Root ZX. The mean difference

20 readings (70%) coincided with the apical

between the actual working length measurements

constriction.

All the readings obtained by Root

and that obtained using Root ZX was mere 0.05

ZX were within 0.5 mm of actual working length.

mm. The results of the present study are in

Conventional radiographic method showed more

agreement with the studies of Found & Reid (1994),9

deviation from the actual working length than the

Czerw and coworkers (1995),10 Shabahang et al

apex locator. Only 7 out of 20 readings (35%)

(1996),11 Katz, Mass & Kaufman (1996),12 Pratten &

coincided with the apical constriction.

McDonald (1996),13 Vajrabhaya & Tepmongkol

(1997)

DISCUSSION

14

Pagavino et al (1998),15 Tselnik et al

(2005).16 With the third generation electronic apex

Accurate working length is a crucial factor for

locator (Root ZX) 70% of the readings coincided

the success of endodontic therapy. Working length

with the apical constriction. When a strict clinical

establishes the apical extent of canal preparation

range of 0.5 mm was considered acceptable, Root

and apical stop. Failure to accurately determine the

ZX located the apical foramen with a clinical

working length may lead to apical perforation,

accuracy of 100%.

pushing of debris beyond the apex and over filling,

with increased incidence of postoperative pain or

The radiographic technique followed was the

may also lead to incomplete instrumentation and

paralleling technique where the film is placed

under filling with attendant problems. Among them

parallel to the long axis of the tooth and the central

should be noted, persistent pain and discomfort

x-ray beam is directed at right angles to the teeth

from inflamed shreds of retained pulpal tissues. In

and film. This was done in accordance to a study

addition, ledge formation may develop, short of

conducted by Forsberg(1987) 17 comparing

the apex, making adequate treatment or retreatment

paralleling and bisecting angle techniques during

extremely difficult or impossible. Finally, apical

endodontic working length. He concluded that the

percolation may develop into the unfilled dead

paralleling technique produces improved images

space at the apex. This could result in a prolonged

as this orientation minimizes geometric distortion,

healing period or continued periradicular lesion

also the use of a long source to object distance

and increased incidence of failure. 6, 7

reduces the size of the apparent focal spot. These

factors result in images with less magnification. 5

Position of apical constriction varies, on an

average it is located 0.5 mm from the apical

In the present study the radiographic method

Therefore 0.5mm

shows statistically comparable results to the actual

from the apical foramen was selected, as the actual

working length, even though the results obtained

working length, that means the entire canal

by Root ZX were closer. The mean deviation of the

instrumentation and obturation should terminate

working length determined by conventional

foramen or major diameter.

2, 8

at this point.
17

ENDODONTOLOGY

MANUEL S THOMAS, SHASHIRASHMI ACHARYA, KUNDABALA M

radiography from the actual working length was -

root parallel to the x-ray beam or the exact location

0.35mm.Though the radiographic method shows

of apical foramen, because position of foramen and

statistically comparable results to the actual working

radiographic apex may not coincide. 18

length, the results obtained by Root ZX were closer.

Radiographs are also technique sensitive and

With the radiographic method only 15% coincided

subjective in their interpretation. Variables in

with the actual working length. When the more

radiographic techniques, angulations and exposure

lax clinical range of 1.0 mm was considered

can distort the image and lead to clinical error.

acceptable, the radiographic method located the

Observer bias may influence interpretation of a

apical foramen with a clinical accuracy of 100%.

radiograph.

19

So variation may exist in the

Even though in this study there was no

radiographic determination of endodontic file

statistically significant difference in the working

length. Substantial variation in both the inter

length determined using the Root ZX and the

examiner and intra examiner interpretation of

conventional radiographic method, when

radiographs has been reported.

compared to actual working length it was evident

Electronic apex locators are particularly useful

from the histogram that the apex locator was more

when the apical portion of the canal system is

reliable than the radiographic method in

obscured by certain anatomic structures, such as

determining the end point correctly. But this does

impacted teeth, tori, zygomatic arch, excessive

not necessarily mean that one method is clinically

bone density, overlapping roots or shallow palatal

more accurate and reliable than the other.13

vaults. Electronic apex locators are currently being

In the clinical settings, it is difficult to achieve

used to determine the working length as an

radiographs free of distortion. Furthermore,

important adjunct to radiographs. Electronic apex

anatomical structures such as the maxillary sinus

locators help to reduce the treatment time and

and the zygomatic arch can interfere with accurate

radiation dose, which may be higher with

radiographic visualization of the roots. Radiographs

conventional radiographic measurements. Apex

are two dimensional in nature and to accurately

locators can be very useful in management of

evaluate the position of the file in the root, not less

inpatients and outpatients. They can be an

than two radiographs should be made by varying

important tool in endodontic treatment in the

the horizontal angulation. Any overextension of the

operating room. They reduce the number of

file will more likely be seen in one of the

radiographs20 which may be important for those

radiographs. However, making two radiographs to

who are very concerned about radiation protection.

determine the file position will expose the patient

An apex locator can be of enormous value in

to twice as much radiation and is still not absolutely

situations where radiation is contraindicated, like

reliable. Patients have become increasingly aware

pregnancy. Electronic apex locators can be used

of the hazards of radiation and are more hesitant

any time during the treatment to reconfirm the

to allow the practitioner to make any radiographs.

working length.

They give little information on the curvature of the

18

ENDODONTOLOGY

A COMPARATIVE EVALUATION OF THE ACCURACY OF THIRD GENERATION ELECTRONIC APEX LOCATOR (ROOT
ZX) AND CONVENTIONAL RADIOGRAPHY TO DETERMINE WORKING LENGTH AN IN VIVO STUDY

CONCLUSION

Electronic apex locator can be trusted when

there is a stable electronic sign with reasonably

The results of the present study concluded that

controlled exudates and without any metallic

the Root ZX determined the working length much

restorations. However, when the sign is unstable-

closer to the actual working length. Working length

particularly with metallic restorations, severely

determined by the conventional radiographic

undermined caries, severe exudation or wide open

method also showed less deviation from the actual

apex- a comparison of the apex locator reading with

working length. Even though there was no

the radiograph is strongly recommended. Further

statistically significant difference between the two

more, in a heavily calcified canal, patency needs

experimental groups, Root ZX showed lesser

to be established before determining the electronic

deviation from actual working length compared to

21

signal of the apical foramen.

11

Besides, the

conventional radiographic method.

electronic apex locator only provides the electronic

CLINICAL SIGNIFICANCE

impedance and not the canal shape. Radiographs,

The third generation apex locators are reliable

although only two dimensional, are the only means

tool for the determination of the working length,

of determining the curvatures, size, shape and

even though the use of intra oral radiography cannot

position of the pulp chamber and root canals and

be ignored. A technique that combines the use of

less frequently aberrant morphological changes that

electronic devices and radiograph will certainly

could affect the course of endodontics 22.

reduce the radiation exposure, since the adjustment

of the lengths of the file would be minimal. 23

TABLES
Table 1. Working length determined by Root ZX (G1), conventional radiography (G2), actual working
length (G3), the difference between G3 and G1, the difference between G3 and G2 and the mean of each
groups in millimeters.
Sample no.

Group 1

Group 2

Group 3

1.

19.5

20.0

19.5

0.0

0.5

2.

17.0

16.5

17.5

-0.5

-1.0

3.

19.0

19.5

19.0

0.0

0.5

4.

17.0

17.0

17.0

0.0

0.0

5.

17.0

16.0

17.0

0.0

-1.0

6.

20.0

20.0

20.5

-0.5

-0.5

7.

17.0

16.0

16.5

0.5

-0.5

8.

17.5

17.5

17.5

0.0

0.0

9.

21.5

21.0

21.5

0.0

-0.5

10.

19.5

18.5

19.5

0.0

-1.0

19

G 1 Diff

G 2 Diff

ENDODONTOLOGY

MANUEL S THOMAS, SHASHIRASHMI ACHARYA, KUNDABALA M

11.

19.5

19.5

19.5

0.0

0.0

12.

21.5

21.0

21.5

0.0

-0.5

13.

17.5

16.5

17.5

0.0

-1.0

14.

17.0

17.0

17.0

0.0

0.0

15.

19.5

18.5

19.5

0.0

-1.0

16.

20.5

19.5

20.0

0.5

-0.5

17.

22.0

21.5

21.5

0.5

0.0

18.

19.5

19.0

19.5

0.0

-0.5

19.

20.0

19.5

19.5

0.5

0.0

20.

20.5

20.5

20.5

0.0

0.0

19.125

18.725

19.075

0.05

-0.35

Mean of working length

Mean of the difference

GRAPHS

Table 2: Mean standard deviation for all groups

in millimeter and the P value for G1 and G2
Groups

Mean SD

20

19.125 1.677

0.895

20

18.725 1.766

0.386

20

19.075 1.632

Group1 (G1)
Root ZX
Group2 (G2)
Conv. radio
Group3 (G3)
Actual WL

Table 3: Occurrence of deviation from the actual

working length
Root ZX

Radiography

At apical constriction 14 (70%) 7 (35%)

Within 0.5 mm

20 (100%) 15 (75%)

Within 1.0 mm

20 (100%)

20

ENDODONTOLOGY

A COMPARATIVE EVALUATION OF THE ACCURACY OF THIRD GENERATION ELECTRONIC APEX LOCATOR (ROOT
ZX) AND CONVENTIONAL RADIOGRAPHY TO DETERMINE WORKING LENGTH AN IN VIVO STUDY

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