CLINICAL RESEARCH

~a, DDS,
Gabriela Serna-Pen
MSc,* Susana Gomes-Azevedo, In Vivo Evaluation of 3
DDS, PhD,* Jorge Flores-
~o, DDS, MSc,*
Trevin Electronic Apex Locators: Root
Elizabeth Madla-Cruz, DDS,
MSc,* Idalia Rodríguez-Delgado, ZX Mini, Apex ID, and Propex
DDS, PhD,* and
Gustavo Martínez-Gonza
†

lez, BS, Pixi
PhD

SIGNIFICANCE
It is essential to know the
reliability of recently launched
electronic apex locators, such
as Apex ID and Propex Pixi, as
well as the modified version of
Root ZX—Root ZX mini.
ABSTRACT
Introduction: The aim of this in vivo study was to compare the accuracy of 3 electronic apex
locators (EALs) (Root ZX mini [J Morita Corp, Tokyo, Japan], Apex ID [SybronEndo, Glendora,
CA], and Propex Pixi [Dentsply Maillefer, Ballaigues, Switzerland]) to determine the working
length. Methods: Thirty single-rooted human teeth that were scheduled for extraction were
selected for the study. Electronic measurements were performed with the 3 EALs. After the
teeth had been extracted, a #10 K-file was used to determine the actual working length, which
was established at 0.5 mm short of the major foramen. The data were statistically analyzed
with analysis of variance (a 5 0.05). Results: No significant differences were found among
the experimental groups (P . .05). The mean distance from the actual working length to the
file tip was 0.163 6 0.032 mm when Root ZX mini was used, 0.343 6 0.032 mm for Propex
Pixi , and 0.012 6 0.008 mm for Apex ID. Conclusions: Under the in vivo conditions of this
study, no statistically significant differences were observed among the 3 EALs. (J Endod
2020;46:158–161.)

KEY WORDS
Apex ID; electronic apex locator; Propex Pixi; Root ZX mini; working length

From the Departments of *Endodontics
and †Statistics, Universidad Auto

noma de
Nuevo L
eon, Monterrey, Nuevo Le
on,
Mexico
Address requests for reprints to
Dr Susana Gomes-Azevedo, Av. Jos
e
Vasconcelos 345-208 Colonia Santa
Engracia, San Pedro Garza García, Nuevo

n, Me
Leo
xico 66267.
E-mail address: susangomaz2602@
yahoo.com
0099-2399/$ - see front matter
Copyright © 2019 American Association
of Endodontists.
https://doi.org/10.1016/
j.joen.2019.10.035
The success of root canal treatment depends on the removal of infected pulp tissue, necrotic material,
and microorganisms from the root canal and achieves homogeneous filling of the entire canal1. Therefore,
determining an accurate working length (AWL) is 1 of the most important steps of endodontic therapy2.
The working length (WL) of a root canal has been defined as “the distance from coronal reference point to
the point at which canal preparation and obturation should terminate”3. Several methods have been used
to determine the WL. To date, radiographs are the most commonly used technique, but the technique is
sensitive to error. Radiographs are subject to distortion and magnification and can be difficult to interpret
because of the lack of 3-dimensional representation4,5.
The use of electronic devices to determine the WL was proposed first by Custer6, and the first
electronic apex locator (EAL) was developed after Suzuki’s investigation of the electrical resistance of oral
tissues7. Although the first and second generation of EALs had poor accuracy in the presence of
electrolytes4, these drawbacks were overcome by third-generation EALs, such as Root ZX (J Morita
Corp, Tokyo, Japan). This EAL measures the quotient between the impedance of 2 frequencies (0.4 and
8 kHz). This device has been reported to have between 82% and 100% accuracy in determining the
minor apical foramen8–10 and is considered the gold standard EAL4,11–13.
Modified versions of Root ZX have been developed, including Root ZX mini (J Morita), which is
based on the same functioning method but has a compact size10,14. The accuracy of this EAL has been
reported to be between 93.4% and 95%10 and 56.2%15 in in vitro studies.
Apex ID (SybronEndo, Glendora, CA) has been recently marketed and, according to the
manufacturer, has an operating mechanism similar to that of Root ZX, with 2 frequencies (0.5 and 5.0
kHz)16. The accuracy of Apex ID in different in vitro studies has been reported to be 93.0% at the apical
foramen (0.0) and 68.5% 1 mm short of the apical foramen16, 69.7% at mark 0.0, and 60.6% at mark 0.5.
Oliveira et al17 reported values of accuracy of between 33% and 70% 1 mm short of the apical foramen
and 93% at the apical foramen.
The recently launched Propex Pixi (Dentsply Maillefer, Ballaigues, Switzerland) is a multifrequency
pocket-sized EAL18. The operating method of this device is similar to the impedance of 2 frequencies,

158 ~a et al.
Serna-Pen JOE  Volume 46, Number 2, February 2020
except that it uses more than 2 frequencies
that measure the rapid change of impedance
as the minor apical foramen is reached4. The
accuracy of Propex Pixi in in vitro studies was
reported to be 87%–93% at the apical foramen
(0.0), 63%–67% 1 mm short of the apical
foramen17, and 80% at 60.5 mm of the minor
diameter19.
The purpose of the present in vivo study
was to evaluate the accuracy of 3 EALs: Root
ZX mini, Propex Pixi, and Apex ID. To our
knowledge, no study has evaluated the
accuracy of these EALs under clinical
conditions in determining the WL in teeth with
mature apices.
MATERIALS AND METHODS
Thirty human maxillary or mandibular single-
rooted teeth with mature apices were enrolled.
The teeth had been scheduled for extraction
for orthodontic, prosthetic, or periodontal
reasons at Universidad Auto
noma de Nuevo
Leo
n. Informed written consent was obtained
from each participant according to the study
protocol approved by the ethics board of
Universidad Auto
noma de Nuevo Leo
n. A
periapical radiograph was made of each
selected tooth. Teeth with metal restorations,
fractures, root resorption, or open apices were
not included. All teeth responded positively to
cold sensitivity tests, and, clinically, all the
pulps were confirmed to be vital on
examination of the pulp chamber. All clinical
procedures and electronic measurements
were performed by a single experienced
operator (operator A) previously trained in the
use of these EALs.
After local anesthesia (Scandonest 2%
Special; Septodont, Saint-Maur-des-Fosse
s,
France) and rubber dam isolation, the cusps or
the incisal edges of the teeth were flattened with
a diamond rotary instrument to obtain a stable
reference point for all measurements. The
crowns were marked with ink to serve as a
reference for the location of the silicone stop.
Endodontic access was obtained, and the
coronal portion of each canal was flared with
Gates-Glidden burs #1, #2, and #3 (Dentsply
Maillefer). The canal was then irrigated with a
saline solution with an endodontic syringe and a
27-G needle (Endo-eze tips; Ultradent
Products, South Jordan, Utah) in order to clean
dentin debris. Excess fluid was removed from
the pulp chamber with a paper point #50. A
computerized method of randomization
designated the order in which EALs were used.
Root ZX mini, Apex ID, and Propex Pixi
were used in accordance with the
manufacturers’ instructions. For the 3 EALs,
the clip was attached to the patient’s lip, and
the electrode was connected to a 10 K-file
JOE  Volume 46, Number 2, February 2020
(Dentsply Maillefer). With Root ZX mini,
measurements were made by advancing the
file in the root canal to just beyond the foramen,
as indicated by the flashing “APEX” bar. The file
was then withdrawn until the LCD display
showed a flashing bar between “APEX” and
“1.” For Apex ID, the file was advanced until the
“APEX” signal was seen on the LCD display
and then withdrawn until the display showed
the 0.5 mark. In the case of Propex Pixi, the file
was advanced within the root canal to as far as
the “OVER” bar appeared and retracted to the
0.0 mark. To avoid overshaping, the manual
for Propex Pixi recommends subtracting
0.5mm to the measure obtained at the 0.0
mark.
Measurements were considered valid if
the reading remained stable for at least 5
seconds. The silicon stop was adjusted at the
reference point, and the distance between the
silicon stop and the file tip was measured with
0.01-mm precision digital calipers (Mitutoyo
Corp, Tokyo, Japan) and recorded as the
electronic length Root ZX mini, the electronic
length Apex ID, and the electronic length
Propex Pixi.
After all measurements had been
performed, each tooth was extracted and
placed in a numbered specimen cup, soaked
in 5.25% sodium hypochlorite solution for 2
hours to remove any residual organic tissue
from the external root surface, and then stored
in 10% formalin solution. Subsequently, all
specimens were examined under a
stereomicroscope (Stemi 305; Carl Zeiss,
Oberkochen, Germany) at !30 magnification
to evaluate the presence of root fractures and
the presence of a completely formed apex.
A second experienced operator
(operator B) established the AWL by inserting a
size 10 K-file (Dentsply Maillefer) until the tip of
the file became visible through the major
foramen under !30 magnification with a
stereomicroscope. When the file tip was
tangential to the major foramen, the silicone
stop was placed at the reference point, the file
was removed from the canal, and the distance
between the silicone stop and the file tip was
measured with a 0.01-mm precision digital
caliper. Each measurement was repeated 3
times and the mean of the values recorded.
Then, 0.5 mm was subtracted from each
average to obtain the AWL of the teeth.
In each case, the AWL was subtracted
from the electronic measurements. Positive
values indicated measurements that exceeded
the AWL (long measurements), whereas
negative values indicated measurements that
were short of the AWL. The AWL
measurements were compared between the 3
EAL measurements using analysis of variance
set at a 5 0.05
In Vivo Evaluation of 3 Electronic Apex Locators
RESULTS
The statistical analysis revealed no significant
differences in the accuracy of Root ZX Mini,
Apex ID, and Propex Pixi in the determination
of the AWL set at 0.5 mm from the major
foramen (P . .05).
Using the Root ZX mini, the mean
distance from the AWL to the file tip was 0.163
6 0.032 mm. The accuracy of the Root ZX mini
in establishing the AWL was 83.33% of the
time to 60.5 mm and 100% of the time to 61
mm. Using the Propex Pixi, the mean distance
from the AWL to the file tip was 0.343 6 0.032
mm. The accuracy of Propex Pixi in
establishing the AWL was 83.33% of the time
to 60.5 mm and 89.99% of the time to 61
mm. Using the Apex ID, the mean distance
from the AWL to the file tip was 0.012 6 0.008
mm. The accuracy of Apex ID in establishing
the AWL was 80% of the time to 60.5 mm and
96.66% of the time to 61 mm (Table 1).
DISCUSSION
The aim of the present study was to evaluate
the accuracy of 3 EALs (Root ZX mini, Propex
Pixi, and Apex ID) under clinical conditions. The
authors are unaware of in vivo studies
evaluating these EALs in determining the WL
by using the canal length as a reference after
tooth extraction and on the same teeth.
According to Wrbas et al20, the same teeth
should be used to precisely compare the
accuracy and differences among types of
EALs in determining the WL.
In the present study, the AWL was
established to be 0.5 mm coronal to the major
foramen as suggested in previous
studies12,21,22. Only teeth extracted from adult
patients for periodontal, orthodontic, or
prosthodontic reasons and confirmed to be
vital were used.
In vivo studies have shown the efficacy
of Root ZX and Root ZX II22–24; however,
studies under clinical conditions on the
performance of Root ZX mini are lacking.
Ex vivo studies have reported no statistical
differences between the measurements
obtained by the original Root ZX versus Root
ZX II (J Morita Corp) and Root ZX mini25. In the
present study, Root ZX mini was accurate in
establishing the AWL 83.33% and 100% of the
time to 0.5 mm and 1 mm, respectively. Our
results differed from those of Da Silva and
Alves15, who reported an efficacy of 56.2%
using a tolerance of 60.5 mm. This
discrepancy might be explained by the
different methodologies; Da Silva et al
performed an in vitro study using the major
foramen as a landmark. Stein et al26 claimed
that the accuracy of an EAL depends on the
159
TABLE 1 - Difference between the Actual Working Length (AWL) and the Electronic Length of Root ZX Mini, Propex Pixi,
and Apex ID
Root ZX Mini
Distance from AWL (mm)* n 5 30 % n 5 30
,21.1 0 0
21.0 to 20.51 0 0
20.50 to 0.0 10 33.33
0.01–0.5 15 50
0.51–1.0 5 16.66
.1.1 0 0
*Negative values indicate measurements short of the AWL.
diameter of the major foramen. Others have
observed that the accuracy of measurements
of EALs varies with the diameter of the minor
foramen27,28. Stoll et al10 reported that Root
ZX mini had the best agreement between true
lengths and meter readings in 3 apical regions
(0–3 mm short of the foramen) in comparison
with Raypex 5 (VDW, Munich, Germany).
In the present investigation, the
percentage of readings within 60.5 mm of the
AWL for Apex ID was 80% and 96.66% for 61
mm. Similarly, de Vasconcelos et al16 reported
comparable performances between Apex ID
and Root ZX for the apical foramen location
using the 0.0/APEX mark. However, Piasecki
et al29, using a micro–computed tomographic
method, evaluated the accuracy of Canal Pro
(Coltene-Endo, Cuyahoga Falls, OH), Root ZX
mini, and Apex ID in determining the apical
foramen (0.0) and 0.5 mark. They reported that
Root ZX mini and Canal Pro exhibited high
accuracy for determining both root canal
lengths; nevertheless, using the 0.0 landmark
Propex Pixi Apex ID
% n 5 30 % deviation of the measurements obtained with
1 3.33 0 0
0 0 3 10
3 10 12 40
22 73.33 12 40
2 6.66 2 6.66
2 6.66 1 3.33
Apex ID resulted in longer measurements.
However, the readings at the 0.5 mark were
accurate.
For the percentage of precise
measurements from Propex Pixi, we found an
accuracy of 83.33% and 89.99% for 60.5 mm
and 1 mm, respectively. Somma et al30
reported statistically similar accuracy among
Dentaport ZX (J. Morita, Tokyo, Japan),
Raypex 5, and Propex II (Dentsply/Maillefer,
Ballaigues, Switzerland) in terms of locating the
major foramen. Our results were consistent
with those reported by Oliveira et al17, who
evaluated the efficacy of Apex ID, Root ZX II,
Propex Pixi, and other EALs under laboratory
conditions in measurements performed 1 mm
short of the AF (21.0) and at it (0.0). They
reported accuracy of 70% and 93% for Apex
ID, 67% and 87% for Propex Pixi, and 50%
and 95% for Root ZX II, respectively.
In the present study, no significant
differences were found in the accuracy of Root
ZX mini, Apex ID, and Propex Pixi in
determining the root canal length. The mean
distance from the AWL to the file tips was
0.163 6 0.032 mm, 0.012 6 0.008 mm, and
0.343 6 0.032 mm, respectively. The standard
EALs is important because it represents the
range of variability in the measurements.
Hence, it is important that the standard
deviation of the measurements determined by
EALs should be low31.
In our investigation, the file tip extended
beyond the major foramen in 10% of the teeth
in the Apex ID group, 16.66% in the Root ZX
mini group, and 13.32% in the Propex Pixi
group. Extended measurements have been
reported previously in the range of 26%–40%.
Because of these results, some authors
suggest that, when determining the WL, the
instrument should be withdrawn
approximately 0.5 mm from the position given
by some EALs20,32.
CONCLUSIONS
Under the conditions of this in vivo study, Apex
ID, Root ZX mini, and Propex Pixi performed
equally well in determining a position 0.5 mm
short of the major foramen.
ACKNOWLEDGMENTS
The authors wish to thank Mrs Enid Rosenstiel
for her assistance with English language
editing.
The authors deny any conflicts of
interest related to this study.

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