Basic ResearchTechnology

Influence of Preflaring on the Accuracy of Length

Determination With Four Electronic Apex Locators
ricson Janolio de Camargo,* Ronald Ordinola Zapata,* Paulo Leal Medeiros,*
E
o Garcia,* Ivaldo Gomes de
Clovis Monteiro Bramante,* Norberti Bernardineli,* Roberto Branda
ngaro Duarte
Moraes,* and Marco Antonio Hu
Abstract
Introduction: The aim of this study was to compare the
influence of preflaring on the accuracy of 4 electronic
apex locators (EALs): Root ZX, Elements Diagnostic
Unit and Apex Locator, Mini Apex Locator, and Apex
DSP. Methods: Forty extracted teeth were preflared
by using S1 and SX ProTaper instruments. The working
length was established by reducing 1mm from the total
length (TL). The ability of the EALs to detect precise
(1mm from TL) and acceptable (10.5mm from TL)
measurements in unflared and preflared canals was
determined. Results: The precise and acceptable (P/A)
readings in unflared canals for Root ZX, Elements Diagnostic Unit and Apex Locator, Mini Apex ,and Apex DSP
were 50%/97.5%, 47.5%/95%, 50%/97.5%, and 45%/
67.5%, respectively. For preflared canals, the readings
were 75%/97.5%, 55%/95%, 75%/97.5%, and 60%/
87.5%, respectively. For precise criteria, the preflared
procedure increased the percentage of accurate electronic readings for the Root ZX and the Mini Apex
Locator (P < .05). For acceptable criteria, no differences
were found among Root ZX, Elements Diagnostic Unit
and Apex Locator, and Mini Apex Locator (P > .05).
Fisher test indicated the lower accuracy for Apex DSP
(P < .05). Conclusions: The Root ZX and the Mini
Apex Locator devices increased significantly the precision to determine the real working length after the preflaring procedure. All the EALs showed an acceptable
determination of the working length between the
ranges of0.5mm except for the Apex DSP device,
which had the lowest accuracy. (J Endod
2009;35:13001302)

Keywords
Electronic apex locator, Root ZX, working length

From the *Department of Endodontics, Bauru Dental

School, University of Sao Paulo, Sao Paulo; and Departament
of Endodontics, University of Sagrado Coracao, Bauru, Brazil.
Address requests for reprints to Clovis Monteiro Bramante,
Al. Octavio Pinheiro Brisola n . 9-75, 17012-901, Bauru, SP,
Brazil. E-mail address: bramante@fob.usp.br.
0099-2399/$0 - see front matter
Copyright 2009 American Association of Endodontists.
doi:10.1016/j.joen.2009.05.030

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Camargo et al.

he establishment and maintenance of working length are a critical step during

endodontic therapy (1). An appropriate microbial disinfection, correct cleaning
and shaping, and hermetic sealing of the root canal depend on the correct determination of working length. The apical constriction is also referred to as the minor constriction diameter and marks the transition between the pulpal and periodontal tissue (2).
This anatomic landmark might be located at 0.51mm from the major foramen (2, 3),
and it has been stated that it is an ideal point to end the instrumentation and obturation
of the root canal system (3).
Traditionally, the working length has been determined by radiographs and electronic apex locators (EALs) (1). The evolution of EALs made the assessment of the
working length more accurate and predictable (46). First, Sunada (4) introduced
the principle of EAL applied for clinical purposes. Then many other appliances were
developed, passing through the first generation of electrical resistancebased EALs
(4) to the second generation impedance-based EALs and the third generation
frequency-based EALs such as the Root ZX (7, 8). In recent years multi-frequency
based apex locator has also been entered into the market (6). A few of these appliances
become more compact devices, which could be easier to operate in many clinical situations, such as the Mini Apex locator (9, 10). The Root ZX measures the impedance of 2
frequencies simultaneously (0.4 and 8kHz) (6) and expresses this quotient in terms of
the position of the file inside the canal. On the other hand, other appliances such as the
Elements Diagnostic Unit and Apex Locator (11) and Apex NRG (Medical NRG, Afikim,
Israel and Septodont, France) are multi-frequencybased devices (12). Gordon and
Chandler (1) classified multi-frequency devices as the fourth generation of EALs.
The coronal flaring of the root canals gives many advantages during the contemporary cleaning and shaping procedures, such as to facilitate the insertion of manual
and rotary instruments into the apical portion of the root canals (13, 14). To date,
only 1 study suggested better accuracy with an EAL when the root canals were preflared
before the instrumentation (14). It is unknown whether new apex locators might
improve their performance after preflaring the root canals before the working length
determination.
The purpose of this in vitro investigation was to evaluate the influence of preflaring
on performance of 4 EALs: Root ZX (J. Morita Corp, Tokyo, Japan), Elements Diagnostic
Unit and Apex Locator (Sybron Endo, Sybron Dental, Anaheim, CA), Mini Apex Locator
(Sybron Endo, Sybron Dental), and Apex DSP (Septodont, Saint-Maur des Fosses,
Cedex, France).

Material and Methods

Selection of Sample
Forty mandibular incisor single-rooted teeth were used in this study. Teeth were
radiographed in both mesiodistal and buccolingual views to verify the absence of root
resorption or canal curvatures. Only root canals with Vertuccis type I canal configuration were used (15). After coronal access, debris and remnants of pulp tissue were
removed with a size 15K-file (Dentsply-Maillefer, Ballaigues, Switzerland). The root
canals were irrigated by using 1% sodium hypochlorite (NaOCl) solution with
a 23-gauge needle. For measurement of the tooth length, the incisal edges were planed
(flattened) by using a polishing machine under refrigeration (APL-4; Arotec, Cotia, SP,

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Brazil). A size 15K-file with a silicone stop was introduced into the root
canal until its tip was seen at the level of the apical foramen (9, 16, 17).
This procedure was performed with the aid of a surgical microscope
(DF Vasconcelos, Sao Paulo, Brazil) at 8.0 magnification. Once the
file tip was observed at the apical foramen, the silicone stop was stabilized at the incisal edge of the tooth. The file was removed, and the
distance between the rubber stop and the file tip was measured with
a 0.5-mm precision ruler (ARCH, Tokyo, Japan). This measure was
defined as the total length of the root canal. The working length was
established by reducing 1mm from the total length.
For electronic measurements of the working length, the teeth were
immersed in a plastic box containing fresh alginate (Jeltrate II; Dentsply, Petropolis, Brazil) (18). Two orifices were made, one in the center
for placing the tooth and the other laterally for placing the lip electrode
of the EALs. Before electronic location, the root canals were irrigated
with 1% NaOCl solution. Cotton pellets were used to remove excess
from the pulp chamber. The lip electrode was immersed in the respective orifice in contact with the conductive medium, and a K-15 file was
then connected to the other electrode for electronic measurement. For
each one of the appliances, a file was gently inserted into the root canal
until the APEX signal was seen on the LED or display screens. The
K-file was gently retracted until the LED or display showed the 1-mm
mark. A rubber stop was then carefully adjusted to the reference level,
and the distance between the rubber stop and the file was measured with
a ruler.
All the canals were measured before and after the preflaring
procedure. For this purpose, the root canals were prepared up to the
middle third with an engine-driven instrument (X-Smart; Dentsply Maillefer) by using the S1 and SX ProTaper instruments (Maillefer). The S1
instrument was introduced into the canal 3mm short of the working
length. Then the SX instrument was used with a brushing motion up
to the middle third. The irrigation was performed with 3mL 1% NaOCl
after the use of each rotary instrument.
Accuracy of the apex locators was classified as the following:
precise, if the measurement was restricted to 1mm short of apical
foramen (correct working length); acceptable, if the measurement
range was restricted to 1mm short of the apical foramen or within
0.5mm of error variation; and mistaken, if the measurement values
were higher or lower than acceptable measurements.
Measurements were recorded on a chart and repeated 3 times, and
an average was calculated. A mean value of these measurements was
recorded for each tooth and analyzed by the c2 test to compare the
number of teeth with precise and acceptable measurements for each
apex locator. A Fisher test was also applied to compare the measurements among the apex locators for each group. The level of significance
was established at P <.05. The analyses were performed with the
GraphPad Prism 4 for Windows (Microsoft Corp, Redmond, WA).

Results
The electronic measurements were done before and after preflaring the root canals, giving a total of 80 averages for each apex locator.
The corresponding percentages and values of precise, acceptable, and
mistaken electronic canal measurements are shown in Fig. 1. Considering 0.5mm of error variation, 2 mistaken electronic readings
were found in the Root ZX and Mini Apex Locator. In both cases, the
errors were found in 1 unflared and 1 preflared canals. Four mistaken
electronic readings were found in the Elements Diagnostic Unit and
Apex Locator device, 2 unflared and 2 preflared canals. For Apex
DSP, 13 and 5 mistaken readings were found in unflared and preflared
canals, respectively. The mean of the distance of mistaken measurements was 1mm short to the working length for the Root ZX, Mini

JOE Volume 35, Number 9, September 2009

Figure 1. Percentage of precise, acceptable, and mistaken readings found in

unflared and preflared canals. Precise measurement, exact electronic readings
at 1mm short from apical foramen; acceptable measurement, value range
restricted to 1mm short of the apical foramen or within 0.5mm of error variation; mistaken measurement, values were higher or lower than acceptable
measurements.

Apex Locator, and Elements Diagnostic Unit and Apex Locator in unflared and preflared canals. For Apex DSP, the range was the same
for unflared and preflared canals, 0.72.3mm short to the working
length. All mistaken measurements were positioned behind the apical
foramen. Chi-square test showed that there was no significant difference
in acceptable measurements for unflared and preflared canals,
irrespective of the device used (P > .05). The preflared procedure
increased the number of precise measurements for all the EALs evaluated (Fig. 1), but this difference was significantly higher for the Root ZX
and the Mini Apex Locator devices (P < .05). Fisher test indicated differences in accuracy between Apex DSP and the other devices (P < .05).

Discussion
The working length should preferably end at the apical constriction, which is the landmark for instrumentation (3, 19). Preflaring of
the root canal during endodontic treatment is important to remove
cervical dentin interferences. Consequently, it allows the file to easily
reach the apical constriction (13, 14) and avoid changes in the working
length. The coronal preflaring procedure is commonly advocated to
teach different instrumentation techniques (20), which include
nickel-titanium rotary systems (21). In addition, Ibarrola et al (14)
stated that this procedure increases the accuracy of the Root ZX device.
Despite several studies that indicate a high accuracy of different devices
for electronic measurements of the working length (10, 2224), it is
unclear whether preflared root canals might affect the precision of
the EALs used in this study.
Different ranges have been used in the evaluation of accuracy of
EALs. Diverse studies have usually considered the electronic measurements for the minor constriction between 0.5mm (9) or 1mm marks
(16, 17). This variation is acceptable because microscopic studies revealed that this landmark might be positioned on this range (2). In vivo
studies have shown that the Root ZX device can precisely locate the
minor diameter within 1mm (22, 23). The 0.5mm of error variation
was established to let the working length be close to the apical constriction and to avoid being beyond the apical foramen, which will not
contribute to success in endodontic treatment (3).
Diverse studies have considered different precision ranges to evaluate the EAL within 0.5mm (19, 22, 23, 25), whereas others use
1mm (26, 27). The precise measurements could not be achieved
in more than 40%47% of the unflared cases (28), which is consistent

Influence of Preflaring on Accuracy of EALs

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with the results of the present study. The tolerance chosen in this study is
considered clinically acceptable and highly accurate (6, 28). This is
important because those specific ranges of 0.5mm or 1mm might
lead to an accuracy variation between 82.3% (19) to 100% (23). Thus,
the precision of some EALs can be overestimated.
In this study different criteria were established to attempt more
reliable interpretations of the electronic readings. The number of
precise readings was superior in the preflared canals for all devices
tested, increasing for acceptable readings by using a0.5-mm tolerance range (Fig. 1). Our data are in agreement with those of Ibarrola
et al (14), which observed a better performance on the Root ZX apex
locator in the preflared mandibular molar canals.
The accuracy among the apex locators used is similar to the results
of other studies: Root ZX (17), Elements Diagnostic Unit and Apex
Locator (17, 29), and Mini Apex Locator (9, 10). The Apex DSP was
impossible to compare with other studies because of the lack of similar
studies. However, lower accuracy for the Apex NRG, a similar device
based also in the digital signal processing technology, had been found
in other in vitro studies that included retreatment (30), foramen variation (16), and simulated root fractures (31).

Conclusion
The Root ZX and the Mini Apex Locator devices increased significantly the precision to determine the real working length after the preflaring procedure. All the EALs showed an acceptable determination of
the working length between the ranges of 0.5mm except for the Apex
DSP device, which had the lowest accuracy.

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