Working Length Determination Using Cone-Beam Computed

Tomography, Periapical Radiography and Electronic Apex

Locator in Teeth with Apical Periodontitis: A Clinical Study

André Luiz Gomide de Morais a, Ana Helena Gonçalves de Alencar b, Cyntia Rodrigues de Araújo Estrela c,
Daniel Almeida Decurcio b, Carlos Estrela b*

a Dental School, Federal University of Goiás, Goiânia, GO, Brazil; b Department of Endodontics, Federal University of Goiás, Goiânia, Go, Brazil; c Department of
Endodontics, University of Cuiabá, Cuiabá, MT, Brazil
ARTICLE INFO ABSTRACT
Article Type: Introduction: The purpose of this clinical study was to compare the accuracy of working
Original Article length (WL) determination using cone-beam computed tomography (CBCT), conventional
Received: 20 Dec 2015 periapical radiographies and electronic apex locator. Methods and Materials: This study was
Revised: 02 Mar 2016 conducted during root canal treatment of 19 patients with a total of 30 single-rooted teeth
Accepted: 12 Mar 2016 diagnosed with apical periodontitis. After taking the initial parallel periapical radiographies,
Doi: 10.7508/iej.2016.03.003 the initial file was advanced into the canal until the WL was detected by the apex locator.
Subsequently, the WL was measured and WL radiographies were taken with the file set in the
*Corresponding author: Carlos canal. Afterwards, CBCT images were acquired. These three measurements were tabulated
Estrela, Department of Oral and compared and the data were analyzed using the Friedman test. The level of significance
Sciences, Federal University of was set at 0.05. Results: The mean values for WL determination by electronic apex locator,
Goiás Praça Universitária s/n, Setor periapical radiograph and CBCT images were 22.25, 22.43 and 22.65, respectively which was
Universitário, Goiânia, GO, Brazil, not statistically significant (P>0.05). Conclusion: Working length determination using CBCT
CEP: 74.605-220. images was precise when compared to radiographic method and electronic apex locator.
Tel: +62-32096254 Keywords: Apical Foramen; Cone-Beam Computed Tomography; Dental Radiography;
Electronic Apex Locator; Tooth Apex
E-mail: [email protected]

Introduction separate meta-analyses by Kojima et al. [4] and Schaeffer et al.

[5], the ideal limit for ending the instrumentation and root canal
he structural complexity of the apical third of the root canals filling was discussed. It was stated that the apical limit is affected
T in teeth with apical periodontitis may hamper the endodontic
therapy. Elimination of microorganisms harbored within the root
by the pathological status of the pulp and periodontium. A
higher success rate was observed when treatment was limited
canal system, depends on the sequence of operative steps, such as short of the radiographic apex.
coronal access, root canal preparation and filling [1, 2]. A better Most endodontists prefer a combination of electronic apex
understanding of variations in the internal anatomy of root canals locators and radiographic methods to determine the WL [6-8].
and obtaining the working length (WL) where the mechanical Although the paralleling technique reduces the dimensional
preparation and chemical irrigation is limited to, is a challenge for changes in the final radiographic image, the ideal orientation of
contemporary endodontics [1-3]. the x-ray tube are difficult aspects to standardize. Distorted
The prognosis of endodontic therapy is strongly influenced radiographic images (stretched or shortened) may result from
by apical limit of root canal instrumentation and obturation. In errors in the vertical positioning of the film or from angulation of

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165 de Morais et al.

the radiographic positioner [7, 8]. Changes in the angle between This study was approved by the Institutional Ethics in
the radiographic film and the tooth have a significant effect on Research Committee of Federal University of Goiás, Goiânia,
linear measures based on periapical radiographies [9, 10]. Brazil. All patients were informed of the study and signed an
Several devices were developed in order to find the most informed consent form.
appropriate length for instrumentation and obturation of root Initial diagnostic radiographies were taken with parallel
canals. The development of new technologies has make technique. Teeth with calcifications of the root canal, internal or
endodontic therapy more rational, less stressful for the external resorption, metallic restorations, root fractures and
professionals and more accurate [11-18]. The electronic apex absence of fully formed root apices, were excluded. All periapical
locators reduce the number of required radiographies and radiographies were obtained using Spectro 70× x-ray machine
minimize the subjectivity involved in radiographic interpretation. (Dabi Atlante, Ribeirão Preto, SP, Brazil), with focal tube of
The basis of WL determination by apex locators include 0.8×0.8 mm and Kodak Insight E-films (Eastman Kodak Co,
electronic measurements of root canal length based on the Rochester, NY, USA). All films were processed in an automatic
resistance, low-frequency oscillation, high frequency, capacitance processor.
and resistance devices, equipment based on voltage gradient, on The root canal treatment of all teeth was performed by an
two frequencies and impedance difference, on two frequencies endodontist who was blinded to the results of the CBCT
and impedance ratio and on multi-frequency impedance. The measurements. The access cavities were prepared using #1012
most current apex locators measure the impedance difference and 2200 diamond burs (KG Sorensen, Agerskov, Denmark).
between two frequencies, or the ratio of two electrical impedances. After locating the root canals they were copiously irrigated
The accuracy of electronic measuring devices has been the subject with 5 mL of 2.5% hypochlorite sodium. The canals were
of numerous studies [5, 11-18]. Its function constitutes to detect explored using a size 15 stainless steel K-file (Dentsply-
an area between the minor and the major foramen, which Maillefer, Ballaigues, Switzerland). The preparation of the
represents the transition between the pulp and periodontal coronal zones of canals was done with # 2 and 3 Gates-Glidden
tissues, point of reference in which endodontic instrumentation drills (Dentsply-Maillefer, Ballaigues, Switzerland) and #1 and
and obturation should terminate preferentially [19-21].
2 Largo burs (Dentsply-Maillefer, Ballaigues, Switzerland).
New imaging modalities have been included in clinical practice,
Then, by advancing a stainless steel K-file that best suited the
such as digital radiography, densitometry, computed tomography,
root canal patency the WL was determined, using an electronic
magnetic resonance imaging, ultrasound and nuclear techniques
apex locator (Root ZX apex locator, J. Morita USA, Inc., Irvine,
[22-28]. These detailed images show the oral structures in a high-
CA, USA). The silicon stopper on the inserted file was then set
resolution and allow the early detection of changes in maxillofacial
structures. Cone-beam computed tomography (CBCT) represents to an anatomical tooth landmark, the file was retracted and the
an important technology recently introduced to dentistry, with high distance between the stopper and the file tip was measured using
potential for clinical application and accuracy compared to a millimeter ruler. After that, the silicon stopper was retreated
periapical radiography. Its contribution to the treatment plan, 1.0 mm and this measurement was noted.
diagnosis, treatment and prognosis of different diseases, besides its The radiographic measurement was made by advancing a
value in research are observed [23-28]. K-file in the root canal, until its tip was 1.0 mm from the root
CBCT scans can be used to allow more accurate WL apex (determined from the measures obtained by the
measurements, offering the advantage of this preexisting electronic apex locator). Radiography was exposed and if the
information [29]. The null hypothesis of this study is related to file tip was not 1.0 mm short from the radiographic apex, the
the absence of differences between the measurement of WL file was repositioned and another radiography was taken to
obtained by the CBCT images, periapical radiographies and ensure that it was in the right measurement. The distance from
electronic apex locators. Thus, the purpose of this clinical study the stop to the file tip was noted.
was to compare the accuracy of WL determined by CBCT with CBCT images were acquired with i-CAT Cone-Beam 3D
periapical radiographies and electronic apex locators. imaging system (Imaging Sciences International, Hatfield, PA,
USA). The tube voltage was 120 kVp and the tube current was
Materials and Methods 3.8 mA. Exposure time was 40 sec. Images were examined with
the scanner’s proprietary software (Xoranversion 3.1.62; Xoran
This preliminary clinical study evaluated 30 single-rooted teeth Technologies, Ann Arbor, MI, USA). The method used to study
(including 13 central incisors, 14 lateral incisors and 3 canines from the root canal WL determination with CBCT was based on
maxilla) from 19 patients (12 female and 7 male patients with the delimiting and measuring the distance between anatomical
mean age of 33.8) referred to Dental Urgency Service of the School landmarks of the dental crowns and roots. All the measurements
of Dentistry of Federal University of Goiás, Brazil, from 2009 to on the CBCT images were acquired by a dental radiology
2010. In all patients the diagnosis was asymptomatic apical specialist, using a proprietary measurement tool supplied with
periodontitis associated with primary infection. the CBCT scanner (Xoran 3.1.62; Xoran Technologies, Ann

IEJ Iranian Endodontic Journal 2016;11(3): 164-168

 Methods of working length determination 166

Arbor, MI, USA). A specific function of i-CAT software that The results of the current study are in accordance with
offers values in millimeters was used to measure tooth images. previous reports which analyzed the potential of CBCT in root-
The measurements were made in the sagittal plane (the reference length measurements [10, 30, 34, 35]. Janner et al. [34] in a pilot
was the largest measurement extension given by the software). investigation evaluated the utility and precision of already
The reference distance used was the maximum width between existing CBCT scans in measuring the endodontic WL, and
the incisal edge or cusp tip and the most apical point of the root. compared it with standard clinical procedures. A strong
The measurement was 1.0 mm short of the root apex (Figure 1). correlation was found between the endodontic WL measured in
The Shapiro-Wilk test was used to verify the distribution of the CBCT images and the electronic apex locator measurements.
aleatory errors around the means (normality). The Friedman Sherrard et al. [10] evaluated the accuracy and reliability of
test was used to compare the WL measured with CBCT, tooth-length and root-length measurements derived from
radiographic imaging or electronic apex locator using SigmaPlot CBCT volumetric data made from 7 fresh porcine heads. CBCT
for Windows (Version 12.0, Systat Software Inc., San Jose, CA, scans are at least as accurate and reliable as periapical
USA). The level of significance was set at 0.05. radiographies for determining root length. Differences between
the length of root canal obturation detected by periapical
Results radiographies and CBCT images were showed by Moura et al.
[30]. Periapical radiographies showed that root canal
obturations were 1-2 mm short of the apex in 88%, 89.3%, and
The mean values of WL was obtained by using the electronic
95% of the anterior teeth, premolars and molars, respectively.
apex locator, the periapical radiographies and CBCT images are
CBCT images showed that root obturation had the same length
described and are presented in Table 1. The distribution of data
in 70%, 73.7%, and 79% of anterior teeth, premolars, and molars,
was not normal (P<0.05). The values obtained by electronic apex respectively. The frequency of apical periodontitis was
locator, periapical radiographies and CBCT images were 22.25, significantly greater in molars compared to the other teeth,
22.43 and 22.65, respectively. No statistical significant regardless of the diagnostic method.
differences were found between the three methods (P>0.05). Despite the well-known benefits and limitations of periapical
radiographies [22-26, 32], and to represent the common devices
Discussion for regulating root canal WL, several professionals have chosen
the electronic apex locator [32, 36, 37]. Shabahang et al. [36]
Different strategies have been used to determine the position of verified that Root ZX was able to locate the foramen with a clinical
the apical foramen and to thus to measure the WL of root canals accuracy rate of 96.2%. Ravanshad et al. [37] compared the effect
[11-19]. The most widely used method is taking periapical of WL determination using electronic apex locator or radiography
radiographies. However, although the accepted place for apical on the length adequacy of final WL as well as the final obturation
constriction is between 0.5 to 1.0 mm from the radiographic in 84 patients. The endodontic treatment using the electronic apex
apex, there are variations in the relationship from that point of locator is quite comparable, if not superior, to radiographic length
reference which result in errors of instrumentation, and that measurement regarding the rates of acceptable and short cases.
obviously influence the position of endodontic filling. The influence of the apical limits determination for root canal
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periapical pathosis in patients who present with contradictory or using electronic apex locator, periapical radiography or CBCT images
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symptoms associated with an endodontically untreated tooth. 22.25 22.43 22.65 0.053

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167 de Morais et al.

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