12140
Department of Conservative Dentistry, School of Dentistry, University of Granada, Granada; and 2Private Practice, M
alaga,
Spain
Abstract
pez JM, Martn JA, Robles V, Gonza
lezLucena C, Lo
Rodrguez MP. Accuracy of working length measurement:
electronic apex locator versus cone-beam computed tomography.
International Endodontic Journal, 47, 246256, 2014.
Introduction
The accurate determination of working length (WL)
has a major impact on the outcome of root canal
246
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
image magnification, distortions or the superpositioning of anatomical structures (Real et al. 2011).
Moreover, because the AC cannot be detected radiographically, the radiographic WL is actually an
estimation based on the average distance between the
constriction and the major foramen. Thus, WL is
often measured 0.51 mm short of the radiographic
apex. Nevertheless, the major foramen does not
always coincide with the anatomical apex, but may
be located laterally (Kuttler 1955, Dummer et al.
1984, ElAyouti et al. 2002) and at a distance of up
to 3 mm from the anatomical apex (Green 1955,
Dummer et al. 1984). The above reasons could
explain the common overestimation of radiographic
WL (ElAyouti et al. 2001, Williams et al. 2006).
Cone-beam computed tomography (CBCT) is a contemporary radiological imaging system that produces
undistorted images with a significantly lower-effective
radiation dose than conventional computed tomography (CT) (Durack & Patel 2012). The CBCT images of
the area of interest can be displayed in mesio-distal,
bucco-lingual or coronal planes or simultaneously in
the three orthogonal planes, affording the clinician a
three-dimensional view of the area of interest (Patel
2009). This improved visualization of root canal
morphology could increase the accuracy of WL
measurements (Jeger et al. 2012). In fact, previous
studies have determined WL from pre-existing CBCT
scans, with results comparable to those afforded by
EALs (Janner et al. 2011, Jeger et al. 2012). However,
more studies are needed to validate the accuracy of
the WL measurements when using CBCT images by
comparing them with actual root canal length.
The accuracy of the latest generation EALs varies
over a wide range (4597.6%), depending on the
device, the acceptable error range (0.5 mm or
1 mm) used and the mark (constriction or apex)
chosen by the operator for readings (Haffner et al.
2005, Goldberg et al. 2008, Cianconi et al. 2010,
Stoll et al. 2010). Many authors (Erdemir et al. 2007,
St
ober et al. 2011, Gomes et al. 2012) have used the
0.5 mark, because it theoretically indicates that the
tip of the file is at the AC. Conversely, it has been
suggested (Gulabivala & Stock 2004) that EALs
should be used with reference to the apex mark,
because the impedance characteristics given for the
canal coronal to the apical foramen cannot be calibrated accurately. However, studies that have evaluated the accuracy of measurements referred to both
apical references (i.e. constriction and apex) are
scarce (Jung et al. 2011). The question therefore
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Electronic measurements
For the electronic measurements, the RayPex 6
number series R6 2011090535 was used. A total of
247
CBCT measurements
The remaining 30 teeth were used for the CBCT measurements (group 5). A model that simulated a lower
jaw was produced, using a model base (Dentalite,
Madrid, Spain) as mould; 15 teeth were included in
each mould using polyvinyl siloxane impression
material (Putty Soft Proclnic S.A., LHospitalet de
Llobregat, Barcelona, Spain).
The CBCT images were obtained with the Planmeca ProMax 3Ds (Planmeca, Helsinki, Finland), with a
basic voxel size of 0.5 mm and FOV 50 9 80 mm.
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2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Figure 2 The measurement line was traced from the reference occlusal plane to the end of the canal.
Figure 3 The multiple-line tracing tool was used to measure curved canals.
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
249
Statistical methods
The sample size was estimated as 26 teeth per group
(a = 0.05, b = 0.05, with a minimum value for clinical relevance of 0.5), but 30 teeth per group were
finally used to compensate potential losses of samples
during the study.
Figure 4 The tip of the file at the level of the most coronal
border of the major foramen.
(a)
(b)
250
Data processing
Differences between electronic/CBCT measurements
and actual length (AL) were calculated. Negative and
positive values indicated measurements that respectively fell long and short of the AL, whilst 0.0 indicated coinciding measurements.
Data analysis
Two-way analysis of variance (ANOVA) was used to
identify possible significant interactions between the
mark (constriction/apex) of the EAL chosen for readings and the condition (dry/NaOCl/distilled water/Ultracain) of the canal.
The KolmogorovSmirnov test revealed a normal
distribution, and the Bonferroni test was then used
for pairwise comparisons amongst groups of irrigating
solutions referred to the apical constriction (AC).
Likewise, one-way-ANOVA and the Welch test were
used to compare means amongst groups of irrigating
solutions and CBCT referred to the major foramen
(MF).
In addition, the differences between the electronic
or CBCT measurements and AL were classified into
three categories:
Precise: Including those measurements coinciding
with the AL;
0.5 mm: Including those differences falling
within 0.5 mm of the AL;
1.0 mm: Including those differences falling
within 1.0 mm of the AL.
The chi-squared and Fishers exact tests were used
to compare percentages of precise, 0.5 mm and
1.0 mm measurements amongst the experimental
groups.
The statistical analysis was carried out accepting a
level of significance of 5%.
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Results
Five teeth were excluded, because of unstable
measurements.
Two-way ANOVA showed a significant interaction
between the mark of the EAL chosen for readings
(constriction/apex) and condition of the root canal
(dry/NaOCl/distilled water/Ultracain) (P < 0.001).
The means and standard deviations of the differences between the electronic or CBCT measurements
and AL are shown in Table 1.
When the constriction mark was taken as reference, the mean differences obtained in the presence
of distilled water and Ultracain were significantly
different from those obtained under dry conditions
or in the presence of 2.5% NaOCl (Table 1,
P < 0.001). Furthermore, electronic measurements
obtained in dry canals and with 2.5% NaOCl were
longer than the AL, whilst in the presence of distilled water and Ultracain, the measurements were
shorter than the AL. When the apex mark was
taken as reference, both electronic measurements
and measurements on CBCT scans tended to fall
short of AL. Nevertheless, no statistically significant
difference was found amongst the irrigating solutions
(P > 0.05).
The mean difference between the electronic
measurements taken with the constriction mark as
reference and AL to the major foramen (ALMF)
ranged from 0.28 to 0.63 mm. The positive sign of
the mean in all the groups indicates that most of the
measurements fell short of the major foramen.
Table 2 shows the percentages of precise, 0.5 and
1.0 mm measurements obtained. Percentages of
0.5 mm electronic measurements to the constric-
Discussion
Because there have been no previous studies on the
accuracy of the Raypex 6, the primary objective of
this study was to determine which reference mark
(constriction or apex) affords a more exact determination of WL with this EAL and to establish whether
Table 1 Mean and standard deviations (mm) of differences between electronic or CBCT measurements and actual length
ALMF-ELF*/ALMF-CBCTL**
ALAC-ELC
Group
1
2
3
4
5
n
30
30
29
26
30
Mean (SD)
0.36
0.31
0.25
0.26
Max
a
(0.39)
(0.35)a
(0.63)b
(0.47)b
1.32
1.06
0.79
0.57
Min
Mean (SD)
0.72
0.45
2.62
1.10
0.12
0.08
0.18
0.05
0.59
(0.31)
(0.24)a
(0.53)a
(0.28)a
(0.48)b
Max
0.64
0.34
0.60
0.50
0.35
ALMF-ELC
Min
Mean (SD)
0.82
0.98
1.70
0.50
1.58
0.31
0.28
0.63
0.47
(0.31)
(0.28)a
(0.59)b
(0.39)ab
Max
0.24
0.26
0.40
0.30
Min
1.05
0.98
2.90
1.20
ALAC, actual length at apical constriction; ELC, electronic length at constriction mark; ALMF, actual length at major foramen;
ELF, electronic length at apex mark; CBCTL, root canal length measured on CBCT scans.
*Applicable in groups 14.
**Applicable in group 5.
Group 1, dry conditions; Group 2, 2.5% NaOCl; Group 3, distilled water; Group 4, Ultracain; Group 5, CBCT. Positive values indicate smaller means than the AL. Negative values indicate greater means than the AL. Maximum, the largest measurement with
respect to AL. Minimum, the shortest measurement with respect to AL. Different small letters denote statistically significant differences between groups (P < 0.001).
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
251
Precise
1
2
3
4
1
2
3
4
5
1
2
3
4
30
30
29
26
30
30
29
26
30
30
30
29
26
2
0
2
1
0
2
2
2
0
0
1
2
3
ALAC-ELC
ALMF-ELF
ALMF-ELC
0.5 mm
(6.7)a
(0)a
(6.9)a
(3.9)a
(0)a
(6.7)a
(6.9)a
(7.7)a
(0)a
(0)a
(3.3)a
(6.9)a
(11.5)a
20
23
20
16
26
29
23
26
14
24
24
15
17
1 mm
(66.7)a
(76.7)a
(68.9)a
(61.5)a
(86.7)ab
(96.7)ab
(79.3)b
(100)a
(46.7)c
(80.0)a
(80.0)a
(51.7)b
(65.4)b
29
28
27
24
30
30
28
26
24
29
30
25
23
(96.7)a
(93.3)a
(93.1)a
(92.3)a
(100)a
(100)a
(96.5)ab
(100)a
(80.0)b
(96.7)a
(100)a
(86.2)b
(88.5)b
the use of different irrigating solutions could significantly affect the accuracy of the measurements
obtained. In addition, the accuracy of the root canal
measurements made from CBCT images with respect
to the AL of the canals was compared.
Locator reliability is generally evaluated by calculating the discrepancy between the electronic measurements and the reference control length and/or by
calculating the percentage of acceptable measurements, that is, the number of measurements of the
device that fall within an arbitrarily pre-established
error range. Taking into account the enormous ana-
Table 3 Frequency (%) of measurements precise/0.5 mm of the AL/1 mm of the AL: comparison between electronic measurements referred to the constriction mark versus the apex mark
0.5 mm
Precise
Group
Constriction
1
2
3
4
30
30
29
26
2 (6.7)
0 (0)
2 (6.9)
1 (3.9)
Apex
0
2
2
2
(0)
(6.7)
(6.9)
(7.7)
Constriction
20 (66.7)
23 (76.7)
20 (68.9)
16 (61.5)*
1 mm
Apex
26
29
23
26
(86.7)
(96.7)
(79.3)
(100)*
Constriction
29 (96.7)
28 (93.3)
27 (93.1)*
24 (92.3)*
Apex
30
30
28
26
(100)
(100)
(96.5)*
(100)*
Precise, measurements coinciding with the corresponding actual length; 0.5 mm, measurements falling within 0.5 mm of the
corresponding AL; 1.0 mm, measurements falling within 1.0 mm of the corresponding AL; Group 1, dry conditions; Group 2,
2.5% NaOCl; Group 3, distilled water; Group 4, Ultracain.
*Denotes statistically significant differences between electronic measurements referred to the constriction mark versus the apex
mark (P < 0.05).
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2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Table 4 Frequency (%) of electronic or CBCT measurements that prove precise, short and long with respect to actual length
ALAC-ELC
ALMF-ELF
ALMF-ELC
Group
Shorter than AL
(>0.5 mm)
Shorter than AL
(0.5 mm)
1
2
3
4
1
2
3
4
5
1
2
3
4
30
30
29
26
30
30
29
26
30
30
30
29
26
1 (3.3)
0 (0)
7 (24.1)
9 (34.6)
3 (10.0)
1 (3.3)
5 (17.3)
0 (0)
15 (50.0)
6 (20)
6 (20)
14 (48.3)
9 (34.6)
1 (3.3)
4 (13.3)
11 (37.9)
8 (30.7)
18 (60.0)
17 (56.6)
13 (44.8)
14 (53.8)
13 (43.3)
20 (66.7)
19 (63.3)
12 (41.4)
12 (46.2)
Precise
2
0
2
1
0
2
2
2
0
0
1
2
3
(6.7)
(0)
(6.9)
(3.9)
(0)
(6.7)
(6.9)
(7.7)
(0)
(0)
(3.3)
(6.9)
(11.5)
Longer than AL
(0.5 mm)
17
19
7
7
8
10
8
10
2
4
4
1
2
(56.6)
(63.3)
(24.1)
(26.9)
(26.7)
(33.3)
(27.6)
(38.5)
(6.7)
(13.3)
(13.3)
(3.4)
(7.7)
Longer than AL
(>0.5 mm)
9 (30.0)
7 (23.3)
2 (6.9)
1 (3.9)
1 (3.3)
0 (0)
1 (3.4)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
ALAC, actual length at apical constriction; ELC, electronic length at constriction mark; ALMF, actual length at major foramen;
ELF, electronic length at apex mark; Group 1, dry conditions; Group 2, 2.5% NaOCl; Group 3, distilled water; Group 4, Ultracain;
Group 5, CBCT; Shorter, measurements shorter than the actual length; Longer, measurements longer than the actual length.
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
253
254
0.5 mm (group 4) and 0.3 mm (group 4), respectively (Table 1). Consequently, to avoid the risk of
overinstrumentation, 0.5 mm should be subtracted
from the Raypex 6 reading referred to the apex
mark or 0.3 mm referred to the constriction mark.
However, because it is difficult to know precisely
the actual distance of the file tip with respect to the
foramen, this correction implies the risk of underestimating the working length. In this experiment, the
shortest measurement in the readings referred to the
apex signal was 0.98 mm coronal to the major foramen (Table 1, group 2), whilst the shortest measurement in the readings referred to the constriction
signal was 1.20 mm with respect to the major foramen (Table 1, group 4). Therefore, if the proposed
correction was applied under these conditions, the file
tip actually would have been located 1.48 mm (in
the former case) and 1.5 mm (in the latter case) coronal with respect to the major foramen. In summary,
under the conditions of this experiment and applying
the proposed correction, the file tip would be located
between 0 mm and approximately 1.5 mm coronal to
the foramen in practically 100% of the cases
(Table 1).
In relation to the canal irrigant factor, although
electronic measurement of the working length in dry
canals or canals irrigated with distilled water is not
included amongst the specifications for using the Raypex 6, due to the great variability in the actual conditions of use of the locators in clinical practice, it was
considered opportune to include both experimental
groups. The results, in agreement with previous studies (Erdemir et al. 2007, Gomes et al. 2012), show
that electronic measurements in dry canals can be
performed with results similar to those obtained in
the presence of NaOCl or Ultracain. On the other
hand, the use of distilled water as irrigant had a negative effect upon the precision of the Raypex 6
although significant differences in percentages of
0.5 mm measurements were only found between
the Ultracain group and the distilled water group
when the locator was used in reference to the apex
signal (Table 2). This result was expected, given that
the conductivity of distilled water (which lacks many
ions such as chlorides, calcium, magnesium or fluoride) can be almost zero (depending on the degree of
distillation).
Regarding the accuracy of the canal measurements
with CBCT, given the low percentage of measurements
within the error range of 0.5 mm obtained (46.7%)
and the magnitude of the discrepancy with respect to
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
AL, it must be concluded that its performance is inferior to that of the Raypex 6. However, the possibility
of contrasting this observation is limited, although two
previous studies (Janner et al. 2011, Jeger et al. 2012)
have used this radiological technique in determining
WL, both were in vivo studies, and they moreover used
the electronic reading obtained with an EAL (Root
ZX) as control for the comparisons, instead of AL.
Thus, with due consideration of these methodological differences, the mean discrepancy found in the
present study between the CBCT measurements and
the actual lengths (0.59 mm) was greater than those
registered by the above-mentioned authors (0.40 mm
according to Janner et al. (2011) and 0.51 mm in the
study published by Jeger et al. (2012)).
Sherrard et al. (2010) evaluated the accuracy and
reliability of tooth length and root length measurements derived from CBCT volumetric data at 0.2, 0.3
and 0.4 mm voxel sizes. They found that the CBCT
measurements were not significantly different from
the actual lengths; however, the 0.4 mm CBCT scans
seemed to be associated with slightly lower reliability
than 0.3 and 0.2 mm voxel sizes. This would be
attributed to the difficulty in clearly identifying the
landmarks, because larger voxel sizes are associated
with decreased spatial resolution. Therefore, the voxel
size used in the present study (0.5 mm) could explain
the significant differences found between the CBCT
measurements and the actual lengths. In addition,
the studies of Janner et al. (2011) and Jeger et al.
(2012) were both in vivo studies. Also, CBCT scans
were made of fresh porcine heads in the study of
Sherrard et al. (2010). In the present study, the teeth
were embedded in a polyvinyl siloxane model, and
this could imply greater difficulty in clearly identifying
the landmark of the end of canal.
On the other hand, of the 53.3% of measurements
that were outside of 0.5 mm range of the AL, all
corresponded to underestimations of the canal length
(Table 4) in contrast to the tendency towards overestimation that characterizes conventional radiography (Stein & Corcoran 1992, ElAyouti et al. 2001).
Conclusions
Under the experimental conditions, the Raypex 6
was more accurate than CBCT scans (at 0.5 mm
voxel size) for WL determination. The Raypex 6 was
more accurate in locating the major foramen than
the apical constriction. The position of the major foramen could be located with great accuracy using
2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Acknowledgements
This research was supported by Ministerio de Ciencia e
Innovacion (Spain) grant MAT2009:09795.
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