Comparison of measurements obtained with hand files or the Canal Leader attached to electronic apex locators: an in vitro study

H. Steffen1, CH. Splieth1 & K. Behr2

1

Department of Operative Dentistry, University of Greifswald, Germany and 2 Dental Practice, Eichenau, Germany

Abstract
Steffen H, Splieth Ch, Behr K. Comparison of measurements obtained with hand files or the Canal Leader attached to electronic apex locators: an in vitro study. International Endodontic Journal, 32, 103107, 1999.

from the radiographic apex to the tip of the file was measured and compared with the results of the electronic length determination. Results For both electronic devices the differences amongst the distribution of the measurements were not statistically significant under the specified conditions (P > 0.05), indicating that the measurements with hand files and with the Canal Leader were identical for the majority of the cases. Conclusions Under the conditions of this study the working length of canals obtained with electronically assisted hand files were similar to those obtained with the electronically assisted mechanical handpiece Canal Leader. Keywords: apex locator, Canal Leader, JUSTY, root canal working length, ROOT ZX

Aim The aim of the present in-vitro study was to combine directly the Canal Leader handpiece (SET, Olching, Germany) with the electronic apex locators ROOT ZX (Morita, Kyoto, Japan) and JUSTY (Yoshida, Tokyo, Japan) to find out whether the working length values thus obtained were identical to those resulting from the combination of the same electronic devices with hand files. Methodology A total of 50 natural extracted teeth with single canals and mature apices were used. A radiograph was used as a control and the distance

Introduction
The correct determination of working length is a crucial factor for the successful preparation of the root canal and thus the long-term success of the root canal therapy (Katz et al. 1991, Weine 1982). The traditional method for the determination of the root canal length is the radiograph, but accuracy is difficult to achieve because the apical constriction cannot be identified, and variables in technique, angulation and exposure distort this image and lead to error (Ingle 1957, Katz et al. 1991). Thus, in addition to radiographic measurements, electronic root canal working length determination has become increasingly
Correspondence: Dr H. Steffen, Department of Operative Dentistry, Dental School, University of Greifswald, Rotgerberstrasse 8, D-17487 Greifswald, Germany.

important. The electronic method eliminates many of the problems associated with radiographic measurements. Its most important advantage over radiography is that it can measure the length of the root canal to the end of the apical foramen, not to the radiographic apex (Kobayashi 1995). The end-point of preparation of the root canal should be at the apical constriction, which is considered to be, in more than 92% of the cases, 0.5 mm from the anatomical apex and an average of 1 mm from the radiographic apex (Kuttler 1955, Chapman 1969). For preparation of root canals, mechanical systems are now often used. Up to the present, however, no combination of apex locators with mechanical preparation handpieces has been examined. Thus, the aim of the present study was to directly combine a

q 1999 Blackwell Science Ltd

International Endodontic Journal, 32, 103107, 1999

103

Comparison between hand files and the Canal Leader Steffen et al.

Figure 1

Experimental design.

well-known mechanical preparation system (Canal Leader, SET, Olching, Germany) with electronic apex locators of the new generation to determine whether results are identical to those obtained from the same apex locators attached to hand files.

Materials and methods

Fifty root canals of natural extracted human teeth with single root canals and mature apices were used in this study. The teeth were cleaned of debris after extraction and stored in 1% thymol solution until required for the purposes of the study. Each tooth was mounted in a special plastic holder in a container and an access cavity prepared. The prepared teeth were immersed in normal saline solution to the level of the cervical line. All canals were checked to ensure the diameter approximated an ISO 15 file. The mechanical preparation handpiece Canal Leader (SET, Olching, Germany) was used with two measuring devices: the ROOT ZX (Morita, Kyoto, Japan) and JUSTY (Yoshida, Tokyo, Japan). These electronic apex locators have two currents with two different frequencies. They detect the narrowest part of the canal by measuring the feedback variation in impedance of the two signals. The current density is greatest at the apical constriction, which is the narrowest part. The method simultaneously measures the impedance of two different frequencies and calculates the position of the electrode inside the canal. Both electronic devices and the Canal Leader were used according to the manufacturer's instructions. Conventional K-files of maximum size ISO 20 with a metallic stop were used as the electrodes in the root canals; the metallic lip clip was used for the counter electrode and was also immersed in the normal saline solution. Before using the electronic devices, the canals were rinsed with 1% NaOCl and dried with a paper point. The file was advanced into the canal until the display of the electronic measuring system read 0.5 mm from the apex and the audible tone indicated that apex was reached. The file was

Figure 2 Canal Leader with metal clip connection to an apex locator.

then secured rigidly into position in the access cavity by using a rapid-curing acrylic. A radiograph with the fixed file was taken in that position and the working length was determined for each canal. The same steps were conducted during mechanical treatment with the Canal Leader. The Canal Leader was connected with a metal clip via a cable to the electronic measuring system without any modification of the apex locators (Figs 1 and 2). All exposures were made with the long cone paralleling technique with a HELIODENT MD (Siemens, Munich, Germany) operated at 60 kV. The exposure time was 0.16 s; Kodak chemical products (New York, USA) were used. The electronic measurements and the radiographs were evaluated by two experienced dentists. The distance from the radiographic apex to the tip of the file was measured using a special millimetre ruler on a light box with 2 magnifications for each canal and compared with the results obtained by electronic length determination. The Kolmogorov--Smirnov analysis was used to test the statistical significance (P < 0.05) of differences between measurements obtained with the hand file/electronic combination and the Canal Leader/electronic combination.

104

International Endodontic Journal, 32, 103107, 1999

q 1999 Blackwell Science Ltd

Comparison between hand files and the Canal Leader Steffen et al.

Results
The ROOT ZX in combination with the hand file was able to insert the tip of the file to a distance of 0.5 1.5 mm from the radiographic apex in 48 of 50 cases; with the Canal Leader, the ROOT ZX showed the same results in 47 cases. In only two cases did the ROOT ZX indicate the apical constriction when the tip of the hand file was already at the radiographic apex. In three cases, the ROOT ZX combined with the Canal Leader indicated the apical constriction when the file tip was at the radiographic apex (Fig. 3). In 45 out of 50 cases, the JUSTY combined with a hand file located the tip of the file within 0.5 1.5 mm from the radiographic apex; with the Canal Leader, 49 cases showed the same degree of accuracy. With hand files, the JUSTY showed the tip of the file at the radiographic apex in four cases, and in combination with the Canal Leader in one case (Fig. 4). The mean difference from the radiographic apex to the tip of the file for all measurements is shown in Table 1. There was no case beyond the radiographic apex. The KolmogorovSmirnov analysis showed that the differences amongst the distribution of the measurements from hand files and the Canal Leader were not statistically significant under the specified conditions

(P > 0.05). The values of the measurements with the Canal Leader plus hand instruments were normally distributed. Altogether, the results showed a good approximation of the desired working length comparing measurements from electronic devices plus hand instruments with those from electronic devices plus the Canal Leader.

Discussion
The ideal method for root canal working length determination must be accurate, easy and quick to apply, and should be comfortable for both patient and clinician. Currently, there is a trend towards a combined method of checking the working length electronically during root canal preparation with a mechanical handpiece. Many authors are in agreement that the subtraction of 1 mm from the tooth length as measured by a radiograph would give consistent results (Seltzer et al. 1963, Vande Voorde & Bjorndahl 1969, Weine 1976, Dummer et al. 1984, McDonald 1992). Other authors also accept a distance of 2 mm coronally from the radiographic apex. Stein & Corcoran (1992) found that the average distance short of the apex as established by Kuttler (1955) should be increased to lie between 1.5

Figure 3 Frequency distribution of endometrically determined values found with the ROOT ZX coupled to hand files and the Canal Leader, compared with those shown radiographically (0 = radiographic apex).

Figure 4 Frequency distribution of endometrically determined values found with the JUSTY coupled to hand files and the Canal Leader, compared with those shown radiographically (0 = radiographic apex).

Table 1

Mean and standard deviation of distances recorded from radiographic apex

Mean distance from radiographic apex Standard deviation (mm) 0.34 0.36 0.44 0.35 Significance, P

ROOT ZX JUSTY

Hand instrument With Canal Leader Hand instrument With Canal Leader

0.78 0.79 0.96 0.93

0.54 0.64

q 1999 Blackwell Science Ltd

International Endodontic Journal, 32, 103107, 1999

105

Comparison between hand files and the Canal Leader Steffen et al.

and 2 mm to improve the safety margin when radiographs are used during instrumentation of the root canal system. In the present study, between 90 and 98% of the measurements ranged from 0.5 to 1.5 mm short of the apex and no measurement lay beyond the radiographic apex. The present results suggest that the clinical testing of this combination can be recommended. One advantage of combining an apex locator for working length measurement and a mechanical preparation handpiece is the possibility of checking the working length continuously during the whole mechanical preparation of the root canal without having to confirm it with a radiograph. Thus, the danger of an over- or under-instrumentation of the canal can minimized. The operating time may be reduced. It does not totally eliminate the need for radiographs, but this combination reduces the number of radiographs needed to establish the working length and to reconfirm lengths. A typical use of the Canal Leader is to locate very narrow root canals initially, and in combination with the ROOT ZX, it can also simultaneously establish the root canal working length. Even very small files, down to ISO 08, may be used for the measurement. At present, clinical testing is being done on patients. Some practice is necessary to become familiar with the devices before accurate measurements can be obtained routinely. Kobayashi (1995) reported a recently developed engine-driven canal preparation system for rotation movement with nickel-titanium files for continuous electronic monitoring during all preparation procedures. Huhn (1997) reported on his initial experience with the newly developed cableless Tri Auto ZX produced by Morita (Kyoto, Japan). The handpiece can reverse the rotation movement if the file tip has reached the apex. Huhn (1997) is convinced of the good protection from overinstrumentation and fractures of the nickel-titanium files, and found that considerable time is gained. There have been no in vivo or in vitro studies on the newly developed handpiece. Our combination of an apex locator with a mechanical preparation handpiece may be used with many different apex locators and mechanical handpieces, not only the Canal Leader. Several studies have shown that current electronic locators are 8395% accurate if used carefully (Inoue & Skinner 1985, Kaufman et al. 1989, McDonald & Hovland 1990, Christie et al. 1993, Saito & Yamashita 1990, Strickling & Ott 1995, Vo & Siebenkees 1994).

McDonald & Hovland (1990) showed in an in vivo study that the Endocater (Hygienic Corp., Akron, OH) located the position of the dentinocemental junction or a position within 0.5 mm short of it in 93.4% of the canals evaluated. Lauper et al. (1996) found in an in vivo study that, with the Apit EM S1 (Osada Electronic Co., Tokyo, Japan), 100% of the measurements were within the 1 mm range, and 93% were within the 0.5 mm range. The electronic apex locators offer a potential method for determining working length with reduced radiation exposure, and to a certain extent they eliminate problems with anatomical variations. However, they do not replace radiographs in treatment completely.

Conclusions
Under the conditions of this in vitro study, which combined the Canal Leader with the apex locators ROOT ZX and JUSTY, the results showed a good approximation of the desired working length comparing electronically assisted hand file measurements with those obtained using the mechanical preparation handpiece Canal Leader, as confirmed with a radiograph control. At present, the clinical testing of this combination can be recommended. Testing with other mechanical preparation systems and other apex locators is planned.

References
Chapman, CE (1969) A microscopic study of the apical region of human anterior teeth. Journal of British Endodontic Society 3, 528. Christie, WH, Peikoff, MD, Hawrish, CE (1993) Clinical observations on a newly designed electronic apex locator. Journal of Endodontics 59, 76572. Dummer, PMH, Mcginn, JH, Rees DG (1984) The position and topography of the apical constriction and apical foramen. International Endodontic Journal 17, 1928. Huhn, Ch (1997) A quantum leap in endodontics. Dental Spiegel 1, 4953. Ingle, JJ (1957) Endodontic instruments and instrumentation. Dental Clinics of North America 1, 805. Inoue, N, Skinner, DH (1985) A simple and accurate way of measuring root canal length. Journal of Endodontics 11, 421. Katz, A, Tamse, A, Kaufmann, AY (1991) Tooth length determination: a review. Oral Surgery, Oral Medicine, Oral Pathology 72, 23842.

106

International Endodontic Journal, 32, 103107, 1999

q 1999 Blackwell Science Ltd

Comparison between hand files and the Canal Leader Steffen et al.

Kaufmann, AY, Szajkis, S, Niv, N (1989) The efficiency and reliability of the Dentometer for detecting root canal length. Oral Surgery, Oral Medicine, Oral Pathology 67, 573. Kobayashi, C (1995) Electronic canal length measurement. Oral Surgery, Oral Medicine, Oral Pathology 79, 22631. Kuttler, Y (1955) Microscopic investigation of root apeces. Journal of the American Dental Association 50, 54452. Lauper, R, Lutz, F, Barbakow, F (1996) An in vivo comparison of gradient and absolute impedance electronic apex locators. Journal of Endodontics 22, 2603. McDonald, NJ (1992) The electronic determination of working length. Dental Clinics of North America 36, 293307. McDonald, NJ, Hovland, EJ (1990) An evaluation of the apex locator Endocater. Journal of Endodontics 16, 512. Saito, T, Yamashita, Y (1990) Electric canal measurement under irrigant. Dentistry in Japan 27, 6572.

Seltzer, S, Bender, B, Turkenkopf, S (1963) Factors affecting successful repair after root canal therapy. Journal of American Dental Association 52, 65263. Stein, TJ, Corcoran, JF (1992) Radiographic working length revisited. Oral Surgery, Oral Medicine, Oral Pathology 74, 796800. Strickling, W, Ott, KH (1995) Clinical study of the root canal measuring system Root ZX. Deutsche Zahnarztliche Wochenschrift 3, 15560. Vande Voorde, HE, Bjorndahl, AM (1969) Estimating endodontic ``working length'' with paralleling radiographs. Oral Surgery, Oral Medicine, Oral Pathology 27, 10610. Vob, A, Siebenkees, J (1994) Experimental and clinical assessment of the endometric devices Apit and Root ZX. Deutsche Zahnarztliche Zeitung 49, 2814. Weine, FS (1982) Endodontic Therapy, 3rd edn. St Louis, USA: CV Mosby Co, pp. 256340.

q 1999 Blackwell Science Ltd

International Endodontic Journal, 32, 103107, 1999

107