Basic Research—Technology

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 Antoˆnio 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;35:1300–1302)

Keywords
Electronic apex locator, Root ZX, working length

From the *Department of Endodontics, Bauru Dental
School, University of Sa˜o Paulo, Sa˜o Paulo; and †Departament
of Endodontics, University of Sagrado Corac¸a˜o, Bauru, Brazil.
Address requests for reprints to Clovis Monteiro Bramante,
Al. Octa´vio Pinheiro Brisola n . 9-75, 17012-901, Bauru, SP,
Brazil. E-mail address: bramante@fob.usp.br.
0099-2399/$0 - see front matter
Copyright ª 2009 American Association of Endodontists.
doi:10.1016/j.joen.2009.05.030

1300

Camargo et al.

T

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 0.5–1mm 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 (4–6). 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 resistance–based 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-frequency–based 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 Fosse´s,
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 Vertucci’s 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,

JOE — Volume 35, Number 9, September 2009

Basic Research—Technology Brazil).05). The K-file was gently retracted until the LED or display showed the 1-mm mark. 1). Measurements were recorded on a chart and repeated 3 times. Diverse studies have considered different precision ranges to evaluate the EAL within 0. All mistaken measurements were positioned behind the apical foramen. The file was removed. the range was the same for unflared and preflared canals. if the measurement was restricted to 1mm short of apical foramen (correct working length). Brazil) at 8. and mistaken readings found in unflared and preflared canals.0 magnification. Dentsply. The level of significance was established at P <. The preflared procedure increased the number of precise measurements for all the EALs evaluated (Fig. the root canals were irrigated with 1% NaOCl solution. Precise measurement. A rubber stop was then carefully adjusted to the reference level. 27). A Fisher test was also applied to compare the measurements among the apex locators for each group. Petropolis. Despite several studies that indicate a high accuracy of different devices for electronic measurements of the working length (10. respectively. 0. This measure was defined as the total length of the root canal. The analyses were performed with the GraphPad Prism 4 for Windows (Microsoft Corp.5-mm precision ruler (ARCH. giving a total of 80 averages for each apex locator. irrespective of the device used (P > . 13 and 5 mistaken readings were found in unflared and preflared canals. the errors were found in 1 unflared and 1 preflared canals. the silicone stop was stabilized at the incisal edge of the tooth. one in the center for placing the tooth and the other laterally for placing the lip electrode of the EALs. exact electronic readings at 1mm short from apical foramen. if the measurement values were higher or lower than acceptable measurements. 22. Four mistaken electronic readings were found in the Elements Diagnostic Unit and Apex Locator device. it is unclear whether preflared root canals might affect the precision of the EALs used in this study. Cotton pellets were used to remove excess from the pulp chamber. a file was gently inserted into the root canal until the ‘‘APEX’’ signal was seen on the LED or display screens. Diverse studies have usually considered the electronic measurements for the minor constriction between 0. Mini JOE — Volume 35. Different ranges have been used in the evaluation of accuracy of EALs. All the canals were measured before and after the preflaring procedure. Chi-square test showed that there was no significant difference in acceptable measurements for unflared and preflared canals. which is the landmark for instrumentation (3. which will not contribute to success in endodontic treatment (3). which is consistent Influence of Preflaring on Accuracy of EALs 1301 . Fisher test indicated differences in accuracy between Apex DSP and the other devices (P < . The coronal preflaring procedure is commonly advocated to teach different instrumentation techniques (20). This variation is acceptable because microscopic studies revealed that this landmark might be positioned on this range (2). The lip electrode was immersed in the respective orifice in contact with the conductive medium. Considering 0. 16. Discussion The working length should preferably end at the apical constriction. Percentage of precise. The corresponding percentages and values of precise. Preflaring of the root canal during endodontic treatment is important to remove cervical dentin interferences. Sa˜o Paulo. For this purpose. In both cases. acceptable. Accuracy of the apex locators was classified as the following: precise. 23. 25). For electronic measurements of the working length.5mm of error variation. The irrigation was performed with 3mL 1% NaOCl after the use of each rotary instrument. it allows the file to easily reach the apical constriction (13. but this difference was significantly higher for the Root ZX and the Mini Apex Locator devices (P < . whereas others use 1mm (26. acceptable. 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. The mean of the distance of mistaken measurements was 1mm short to the working length for the Root ZX. Brazil) (18). For each one of the appliances. the root canals were prepared up to the middle third with an engine-driven instrument (X-Smart. the teeth were immersed in a plastic box containing fresh alginate (Jeltrate II. The 0. and an average was calculated. Before electronic location. 17).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. and the distance between the rubber stop and the file tip was measured with a 0. values were higher or lower than acceptable measurements. The working length was established by reducing 1mm from the total length. Ibarrola et al (14) stated that this procedure increases the accuracy of the Root ZX device. Dentsply Maillefer) by using the S1 and SX ProTaper instruments (Maillefer).05). September 2009 Figure 1. Results The electronic measurements were done before and after preflaring the root canals. Redmond. 23).3mm short to the working length. and a K-15 file was then connected to the other electrode for electronic measurement. Then the SX instrument was used with a brushing motion up to the middle third. For Apex DSP. mistaken measurement.5mm of error variation. if the measurement range was restricted to 1mm short of the apical foramen or within 0.5mm (9) or 1mm marks (16. 2 mistaken electronic readings were found in the Root ZX and Mini Apex Locator. Once the file tip was observed at the apical foramen. 1. value range restricted to 1mm short of the apical foramen or within 0. The precise measurements could not be achieved in more than 40%–47% of the unflared cases (28).5mm (19. Consequently. 22–24). acceptable. and Elements Diagnostic Unit and Apex Locator in unflared and preflared canals. In addition.5mm of error variation.05). Number 9. For Apex DSP. The S1 instrument was introduced into the canal 3mm short of the working length. In vivo studies have shown that the Root ZX device can precisely locate the minor diameter within 1mm (22. which include nickel-titanium rotary systems (21). Apex Locator. This procedure was performed with the aid of a surgical microscope (DF Vasconcelos. and mistaken.05. and mistaken electronic canal measurements are shown in Fig. 19). 17). and the distance between the rubber stop and the file was measured with a ruler. acceptable measurement.7–2. 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. 2 unflared and 2 preflared canals. WA). Japan). Two orifices were made. Tokyo. 14) and avoid changes in the working length.

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