Blackwell Publishing IncMalden, USAAEJAustralian Endodontic Journal1329-19472006 Australian Society of Endodontology20063226469Original ResearchAccuracy of Three EALsA. K.

Ebrahim
et al.

Aust Endod J 2006; 32: 6469

ORIGINAL RESEARCH

Accuracy of three different electronic apex locators in detecting

simulated horizontal and vertical root fractures
Aqeel K. Ebrahim, BDS; Reiko Wadachi, DDS, PhD; and Hideaki Suda, DDS, PhD
Pulp Biology and Endodontics, Department of Restorative Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan

Keywords
agar, electronic apex locator, horizontal root
fracture, vertical root fracture.
Correspondence
Dr Aqeel Khalil Ebrahim, Pulp Biology and
Endodontics, Department of Restorative
Sciences, Graduate School, Tokyo Medical and
Dental University, 1-5-45 Yushima, Bunkyo-Ku,
Tokyo 113-8549, Japan. Email:
aqeel_endo@hotmail.com
doi: 10.1111/j.1747-4477.2006.00020.x

Abstract
The aim of this in vitro study was to evaluate the accuracy of three electronic
apex locators (EALs): Root ZX, Foramatron D10 and Apex NRG, in the detection
of fractures in teeth having simulated horizontal and vertical root fractures. A
total of 90 extracted intact, straight, single-rooted teeth were divided into six
groups of 15 teeth each. In Groups A, B and C, an incomplete horizontal fracture
was simulated by preparing a horizontal incision in the coronal, middle or apical
portion of the root until the circumferential half of the canal was exposed in the
horizontal plane respectively. In Groups D, E and F, an incomplete vertical root
fracture was simulated by preparing a vertical straight incision to expose the
canal in the coronal, middle or apical portion of the root all the way in the longitudinal plane respectively. The simulated fractures were 0.25 mm in thickness
in all groups. The teeth were embedded in 1% agar and the canals were irrigated
with saline solution during electronic measurement. Detection of the simulated
root fractures was established with a size 10 K-file when the meter value
reached APEX on each EAL. In Groups A, B and C, KruskalWallis tests
revealed that there were no statistically significant differences between the
three EALs. However, statistically significant differences were found among the
EALs in Groups D, E and F (P < 0.0001, one-way ANOVA and Tukeys post-hoc
test). In conclusion, the three EALs tested were accurate and acceptable clinical
tools in the detection of horizontal root fractures. However, the three EALs were
unreliable in detecting the position of vertical root fractures.

Introduction
Electronic apex locators (EALs) have been used clinically
for more than 40 years as an aid to determine the root
canal working length. These devices, when connected to
a file, can detect the point at which the file leaves the
tooth and enters the periodontium. In 1962, Sunada
demonstrated that the electrical resistance between the
periodontal ligament and oral mucosa had a constant
value (1). As a result, a number of EALs were developed
for use as clinical aids in canal length measurement.
Unfortunately, many EALs are inaccurate in root canals
that contain electrolytes such as blood, tissue and intracanal irrigants (24). In 1983, Ushiyama described the
gradient impedance method to determine working
length in the presence of electrolytes (5). Then,
64

Kobayashi et al. (6) overcame the main shortcoming of

early EALs and developed a new EAL (7), which simultaneously calculated the ratio of two impedances in the
same canal using two different current frequencies,
and determined canal length even in the presence of
electrolytes.
All modern EALs are able to detect root perforations and
lateral canals within a clinically acceptable limit (810).
Azabal et al. (11) found that the Justy II EAL could detect
simulated horizontal fractures. This may aid in decisionmaking and consideration of treatment options (12,13).
Any connection between the root canal and the periodontal membrane, such as root fracture, cracking and internal
or external root resorption will be recognised by the EAL,
which serves as an excellent diagnostic tool in these
circumstances (12,14).

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Journal compilation 2006 Australian Society of Endodontology

Accuracy of Three EALs

A. K. Ebrahim et al.

The aim of this in vitro study was to evaluate three different EALs with respect to their accuracy in detecting simulated horizontal and vertical root fractures.

(a)

(b)

(c)

~1/4
~1/2
~3/4

Materials and methods

Three EALs were used in this study: Root ZX (J. Morita
Co., Tokyo, Japan), Foramatron D10 (Parkell Electronic
Division, Farmingdale, NY, USA) and Apex NRG (Kibbutz
Afikim, Israel).
A total of 90 extracted intact, straight, single-rooted
human teeth with completely formed roots that had been
stored in distilled water containing 10% formalin were
used. No information was available regarding the reasons
for their extraction. Digital dental radiographic images in
both bucco-lingual and mesio-distal directions were taken
to evaluate the root canal anatomy. The crowns of the
teeth were removed with a low speed diamond blade
(Isomet, Buehler, IL, USA) under copious water-cooling
to standardise the root length to 15 mm and to allow
access to the root canal and establish a reference level for
all measurements. The canal length was confirmed by
inserting a size 10 K-file (Zipperer, Munich, Germany)
until the tip of the file became visible at the major apical
foramen. The teeth were then randomly divided into six
groups of 15 teeth each.
In Groups A, B and C, an incomplete horizontal root
fracture was simulated by preparing a horizontal incision
with a diamond disc (Shofu Inc. Kyoto, Japan) in the coronal, middle or apical portion until the circumferential half
of the canal was exposed in the horizontal plane as shown
in Figure 1ac. In Group D, an incomplete vertical root
fracture was simulated by preparing a vertical straight
incision with a TC-11 diamond bur (Mani, Tochigi, Japan)
to expose the canal all the way from the coronal to the
middle portion of the root in the longitudinal plane as
shown in Figure 1d. In Group E, an incomplete vertical
root fracture was simulated by preparing a vertical straight
incision with a bur to expose the canal all the way in the
middle portion of the root in the longitudinal plane as
shown in Figure 1e. In Group F, an incomplete vertical
root fracture was simulated by preparing a vertical straight
incision with a bur to expose the canal all the way from the
middle to the apical portion of the root in the longitudinal
plane as shown in Figure 1f. The thickness of the simulated horizontal and vertical root fractures was approximately 0.25 mm.
A polystyrene specimen bottle (20 mL, Iuchi, Osaka,
Japan) was used to fix the tooth. An adequate amount of
1% agar (Bacto-Agar; Difco Laboratories, Detroit, MI,
USA) was filled into the bottle. Each tooth was embedded
in the agar, leaving a coronal 2 mm of the root, which was
fixed to the lid of the bottle with self-curing resin. The

2006 The Authors

Journal compilation 2006 Australian Society of Endodontology

(d)

(e)

(f)

~1/2

~1/2

~1/2

Figure 1 (a) Horizontal root fracture in the coronal portion. (b) Horizontal
root fracture in the middle portion. (c) Horizontal root fracture in the apical
portion. (d) Vertical root fracture in the coronal portion. (e) Vertical root
fracture in the middle portion. (f) Vertical root fracture in the apical portion.

tooth was kept in that position until the agar had set completely. During electronic measurements, the canal was
irrigated with saline solution using an endodontic syringe
with a 27-gauge needle (Nissho, Osaka, Japan).
To establish an electrical circuit for the EALs, a metal clip
was connected to a stainless steel screw and the instrument clip was attached to a size 10 K-file as shown in other
reports (15,16). Detection of the simulated horizontal and
vertical root fractures was established when the meter
value reached APEX on each EAL. Then, a rubber stop on
the file was carefully adjusted to the reference level and
the distance between the rubber stop and the file tip was
measured with a digital caliper (Sankin, Mitutoyo Co.,
Kanagawa, Japan) to the nearest 0.01 mm. To confirm the
location of each simulated root fracture in Groups A, B and
C, the root was removed from the agar and the distance
between the reference level and the horizontal fracture
was measured with a size 10 K-file under a digital microscope (VH-8000; Keyence, Osaka, Japan) at 20 magnification and recorded. In Group D, the length up to the
coronal end of the simulated fracture was determined
with a size 10 K-file and recorded. In Group E, the roots
were horizontally sectioned at the upper and lower levels
of vertical fractures, while in Group F, the roots were horizontally sectioned at the upper level of the vertical fractures with a disc. The length was then measured with a
size 10 K-file under a digital microscope at 20 magnification and recorded. The measurement was repeated
three times for each sample and the average value was
calculated.
65

Accuracy of Three EALs

A. K. Ebrahim et al.

Statistical analysis
For each reading, the error in measurement was calculated as the absolute difference between the electronically
measured canal length and the location of simulated root
fracture. A non-parametric ANOVA test (KruskalWallis)
was used to find the statistical differences between the
results obtained from Groups A, B and C. In Groups D, E
and F, data were analysed using the one-way analysis of
variance (ANOVA) and Tukeys post-hoc test. A statistically
significant difference was determined at a 95% confidence
level. The analyses were carried out with SPSS version
11.5 (SPSS Inc., Chicago, IL, USA).

test) (Figs 2,3). No statistically significant differences were

found between Foramatron D10 and Apex NRG (P =
0.698). The measurement error showed the largest absolute difference with the Apex NRG in Groups D, E and F
(12.50, 3.88 and 2.35 mm) and the smallest measurement
error with the Root ZX (9.38, 2.54 and 1.50 mm) respectively. In Groups D, E and F, the measurement error
obtained with the Foramatron D10 was 12.23 mm,
3.71 mm and 2.22 mm respectively.

Discussion

The experimental results are summarised in Tables 13. In

Groups A, B and C, no statistically significant differences
were found between the three EALs (P > 0.05, Kruskal
Wallis test). In contrast, statistically significant differences
were found in Groups D, E and F, between Root ZX and
Foramatron D10, and between Root ZX and Apex NRG
EALs (P < 0.0001, one-way ANOVA and Turkeys post-hoc

The main purpose of this in vitro study was to evaluate the

accuracy of three different EALs in detecting simulated
horizontal and vertical root fractures. It has been suggested that EALs operate based on the principle of electricity rather than the biologic properties of the tissues
involved (17). Therefore, in vitro models in which
extracted teeth are immersed in media with similar electrical resistance to the periodontium can provide valuable
information on the function of EALs (15,16,1822). In the
current study, 1% concentration of agar was used as a
medium to simulate the normal periodontium. This agar

Table 1 Measurement results for Root ZX in all groups (I) horizontal root
fracture (II) vertical root fracture

Table 2 Measurement results for Foramatron D10 in all groups (I) horizontal root fracture (II) vertical root fracture

Results

(I)

(I)

Group A

Group B

Group C

Difference (mm)

n (%)

n (%)

n (%)

0.5
0
0.5
1.0

1 (6.6)
13 (86.6)
1 (6.6)

1 (6.6)
12 (80)
1 (6.6)
1 (6.6)

2 (13.3)
12 (80)
1 (6.6)

Group D

Group E

Group F

n (%)

n (%)

n (%)

Group A

Group B

Group C

Difference (mm)

n (%)

n (%)

n (%)

1.0
0.5
0
0.5
1.0

1 (6.6)
2 (13.3)
10 (66.6)
1 (6.6)
1 (6.6)

1 (6.6)
1 (6.6)
11 (73.3)
1 (6.6)
1 (6.6)

2 (13.3)
1 (6.6)
11 (73.3)
1 (6.6)

(II)

Difference (mm)
1.0
1.5
2.0
2.5
8.5
9.0
9.5
10.0
10.5
11.0
11.5
12.0
12.5
13.0

5 (33.3)
4 (26.6)
2 (13.3)
4 (26.6)
1 (6.6)
1 (6.6)
1 (6.6)
2 (13.3)
3 (20)
2 (13.3)
1 (6.6)
1 (6.6)
2 (13.3)
1 (6.6)

n, number of samples; %, percentage in each group.

66

9 (60)
6 (40)

(II)

Difference (mm)
1.5
2.0
2.5
3.0
3.5
10.0
10.5
11.0
11.5
12.0
12.5
13.0
13.5

Group D

Group E

Group F

n (%)

n (%)

n (%)

4 (26.6)
3 (20)
4 (26.6)
4 (26.6)

2 (13.3)
12 (80)
1 (6.6)

1 (6.6)
1 (6.6)
2 (13.3)
1 (6.6)
2 (13.3)
3 (20)
2 (13.3)
3 (20)

n, number of samples; %, percentage in each group.

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Journal compilation 2006 Australian Society of Endodontology

Accuracy of Three EALs

A. K. Ebrahim et al.

Table 3 Measurement results for Apex NRG in all groups (I) horizontal root
fracture (II) vertical root fracture

(a)
0.5

Difference (mm)
1.5
1.0
0.5
0
0.5
1.0

Group A

Group B

Group C

n (%)

n (%)

n (%)

1 (6.6)
1 (6.6)
10 (66.6)
1 (6.6)
2 (13.3)

1 (6.6)
1 (6.6)
1 (6.6)
10 (66.6)

2 (13.3)
1 (6.6)
11 (73.3)

2 (13.3)

1 (6.6)

Mean error (mm)

(I)

0.2

0.1

Root ZX

Foramatron D10

Apex NRG

Root ZX

Foramatron D10

Apex NRG

Root ZX

Foramatron D10

Apex NRG

(b)
0.5

Group E

Group F

n (%)

n (%)

n (%)

2 (13.3)
4 (26.6)
5 (33.3)
4 (26.6)

1 (6.6)
11 (73.3)
3 (20)

1 (6.6)

2 (13.3)
3 (20)
2 (13.3)
4 (26.6)
1 (6.6)
2 (13.3)

n, number of samples; %, percentage in each group.

Mean error (mm)

Group D

0.4

0.3

0.2

0.1

(c)
0.5

Mean error (mm)

1.5
2.0
2.5
3.0
3.5
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0

0.3

(II)

Difference (mm)

0.4

0.4

0.3

0.2

0.1

model has been shown to be an effective tool for evaluating EALs and familiarises the operator with electronic root
canal length measurement (15,16,18,19).
In theory, EALs would mark the first zone having a periodontal communication. This communication could be a
crack, fracture, perforation (8,23) or lateral canal (10). In
the present study, different shapes of root fractures were
simulated with a diamond disc or bur, producing an incision of approximately 0.25 mm thickness. Clinical situations may differ from those incisions, which are probably
narrower or of different shapes. In this study, three different locations of horizontal and vertical root fractures were
simulated and three different EALs were evaluated to
observe whether any discrepancy existed in the detection
of a root fracture.
Many studies used an error range of 0.5 mm to assess
the accuracy of the EAL (24,25). Measurements obtained
within this tolerance are considered highly accurate. In
this study, all EALs detected the position of simulated horizontal root fractures accurately. In Groups A, B and C, the
Root ZX detected the horizontal root fracture within
0.5 mm in 15 cases (100%), 14 (93.3%) and 15 (100%)
2006 The Authors
Journal compilation 2006 Australian Society of Endodontology

Figure 2 (a, b and c) Mean error and standard deviation of absolute differences between the electronically measured canal length and the location
of simulated horizontal root fractures measured by three electronic apex
locators for Groups A, B and C.

respectively. In Groups A, B and C, the Foramatron D10

and Apex NRG detected the horizontal root fracture
within 0.5 mm in 13 (86.6%) and 12 (80%), 12 (80%)
and 11 (73.3%), and 12 (80%) and 12 (80%) respectively.
The results of Groups A, B and C were in agreement with
those of Azabal et al. (11), who found that the Justy II EAL
was able to detect simulated horizontal root fractures correctly in an in vitro study.
In a previous study examining the accuracy of EALs in
both horizontal and vertical root fractures, Azabal et al.
(11) reported that the Justy II EAL was unreliable in
detecting vertical root fractures. The results in Groups D, E
and F were in agreement with these findings of Azabal
et al. (11). The three EALs in this study were unreliable in
detecting the position of vertical root fractures. However,
67

Accuracy of Three EALs

A. K. Ebrahim et al.

Mean error (mm)

(a)
*

14
12
10
8
6
4
2
0
Root ZX

Foramatron D10

(b)

Apex NRG

4
3

References

1. Sunada I. New method for measuring the length of the root

canal. J Dent Res 1962; 41: 37587.
2. ONeill LJ. A clinical evaluation of electronic root canal
measurement. Oral Surg Oral Med Oral Pathol 1974; 38:
46973.
3. Trope M, Rabie G, Tronstad L. Accuracy of an electronic
apex locator under controlled clinical conditions. Endod
Dent Traumatol 1985; 1: 1425.
4. McDonald NJ, Hovland EJ. An evaluation of the apex locator endocater. J Endod 1990; 16: 58.
5. Ushiyama J. New principle and method for measuring the
root canal length. J Endod 1983; 9: 97104.
6. Kobayashi C, Okiji T, Kawashima N, Suda H, Sunada I. A
basic study on the electronic root canal length measurement: Part 3. Newly designed electronic root canal length
measuring device using division method. Jpn J Conserv
Dent 1991; 34: 14424.
7. Kobayashi C, Suda H. New electronic canal measuring
device based on the ratio method. J Endod 1994; 20:
11114.
8. Fuss Z, Assooline LS, Kaufman AY. Determination of location of root perforations by electronic apex locators. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82:
3249.
9. Kaufman AY, Fuss Z, Keila S, Waxenberg S. Reliability of
different electronic apex locators to detect root perforations
in vitro. Int Endod J 1997; 30: 4037.
10. Goldberg F, Artaza LP, De Silvio A. Effectiveness of different obturation techniques in the filling of simulated lateral
canals. J Endod 2001; 27: 3624.
11. Azabal M, Garcia-Otero D, de la Macorra JC. Accuracy of
the Justy II apex locator in determining working length in
simulated horizontal and vertical fractures. Int Endod J
2004; 37: 1747.
12. Nahmias Y, Aurelio JA, Gerstein H. Expanded use of the
electronic canal length measuring devices. J Endod 1983;
9: 3479.
13. Kaufman AY, Keila S. Conservative treatment of root perforations using apex locator and thermatic compactor
case study of a new method. J Endod 1989; 15: 26772.

1
0
Root ZX

Foramatron D10

Apex NRG

(c)
*

Mean error (mm)

*
2

0
Root ZX

Foramatron D10

Apex NRG

Figure 3 (a, b and c) Mean error and standard deviation of absolute differences between the electronically measured canal length and the location
of simulated vertical root fractures measured by three electronic apex
locators for Groups D, E and F. *Statistically signicant (P < 0.0001, one-way
ANOVA).

in Groups D, E and F, the Root ZX showed significantly

better scores than Foramatron D10 and Apex NRG.
In root perforations or fractures, the accuracy of the
EAL is important to prevent under- or over-instrumentation. The present study and some previous studies indicate
that, even in fully controlled in vitro study conditions,
there is some inconsistency in EAL measurements
(15,16,19,26). It should be emphasised that the results
obtained in this in vitro study cannot be directly extrapolated to the clinical situation, but can provide an objective
examination of a number of variables that are not practical
to test clinically.

Conclusion
Under the conditions of this study, the three EALs tested
were accurate and acceptable clinical tools for detecting
the position of horizontal root fractures. However, the
68

Acknowledgment
We express special thanks to Dr Pallegama Ranjith for his
kind advice in the statistical analysis of this research.

*
5

Mean error (mm)

Root ZX was more accurate in the detection of horizontal

root fractures than the other EALs tested. In contrast, the
three EALs were unreliable in detecting the position of
vertical root fractures. However, the Root ZX showed
significantly better scores than the other EALs for the
detection vertical root fractures. More clinical studies are
needed to further evaluate EALs.

2006 The Authors

Journal compilation 2006 Australian Society of Endodontology

A. K. Ebrahim et al.

14. Chong BS, Pitt Ford TR. Apex locators in endodontics:

which, when and how? Dent Update 1994; 21: 32830.
15. Ebrahim AK, Yoshioka T, Kobayashi C, Suda H. The effects
of file size, sodium hypochlorite and blood on the accuracy
of Root ZX apex locator in enlarged root canals: an in vitro
study. Aust Dent J 2006; 51 (in press).
16. Ebrahim AK, Wadachi R, Suda H. Ex vivo evaluation of the
ability of four different electronic apex locators to determine the working length in teeth with various foramen
diameters. Aust Dent J 2006; 51 (in press).
17. Huang L. An experimental study of the principle of electronic root canal measurement. J Endod 1987; 13: 604.
18. Fouad AF, Krell KV. An in vitro comparison of five root
canal length measuring instruments. J Endod 1989; 15:
5737.
19. Fouad AF, Rivera EM, Krell KV. Accuracy of the Endex
with variations in canal irrigants and foramen size. J Endod
1993; 19: 637.
20. Aurelio JA, Nahmias Y, Gerstein H. A model for demonstrating an electronic canal length measuring device.
J Endod 1983; 9: 5689.

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Journal compilation 2006 Australian Society of Endodontology

Accuracy of Three EALs

21. Donnelly JC. A simplified model to demonstrate the operation of electronic canal length measuring devices. J Endod
1993; 19: 57980.
22. Czerw RJ, Fulkerson MS, Donnelly JC. An in vitro test
of a simplified model to demonstrate the operation of
electronic root canal measuring devices. J Endod 1994; 20:
6056.
23. Pallars A, Faus V. An in vivo comparative study of two apex
locators. J Endod 1994; 20: 5769.
24. Dunlap CA, Remeikis NA, BeGole EA, Rauschenberger CR.
An in vivo evaluation of an electronic apex locator that uses
the ratio method in vital and necrotic canals. J Endod 1998;
24: 4850.
25. Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod 1998;
24: 43841.
26. Saito T, Yamashita Y. Electronic determination of root canal
length by newly developed measuring device influences
of the diameter of apical foramen, the size of K-file and
the root canal irrigants. Dent Jpn (Tokyo) 1990; 27: 65
72.

69