ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY  Evaluation of the accuracy of four electronic apex locators  Propex II Root ZX Ipex Neosono Copilot to determine the working le
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ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY Evaluation of the accuracy of four electronic apex locators Propex II Root ZX Ipex Neosono Copilot to determine the working le

ECS Maaruti College of Dental Sc iences and Research CentreBangalore ABSTRACT Objectives To evaluate the four electronic apex locators namely Propex II Root ZX Ipex Neosono Copilot to determine the working length in teeth with simulated oblique root

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ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY Evaluation of the accuracy of four electronic apex locators Propex II Root ZX Ipex Neosono Copilot to determine the working le




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Presentation on theme: "ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY Evaluation of the accuracy of four electronic apex locators Propex II Root ZX Ipex Neosono Copilot to determine the working le"— Presentation transcript:


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89 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 89 Evaluation of the accuracy of four electronic apex locators - Propex II, Root ZX, Ipex, Neosono Co-pilot to determine the working length in teeth with simulated oblique root fracture - An in vitro study RAGHU SRINIVASAN * KALPANA KANYAL ** * Professor and HOD, ** P G Student, Department of Conservative Dentistry and Endodontics, A.E.C.S Maaruti College of Dental Sc iences and Research Centre,Bangalore. ABSTRACT Objectives: To evaluate the four electronic apex locators namely (Propex II, Root ZX, Ipex,

Neosono Co-pilot) to determine the working length in teeth with simulated oblique root fracture. Study design: Thirty permanent maxillary incisors were used. Standard access cavities were prepared. An incomplete notch was made simulating an oblique root fracture. True working length with respect to the fracture plane was determined. A model was prepared for measuring the working length using apex locator. Data was compared with the true working length, allowing a tolerance of 0.5mm and 1mm. Analysis of variance and chi-square test were performed to analyze the results. Results: All the apex

locators were more accurate and statistically similar at 1mm tolerance. At 0.5mm tolerance, statistically significant differences were found. Conclusion : A tolerance limit of 1mm can be considered acceptable, especially in cases of oblique root fracture Key words : Apical limit, oblique root fracture, electronic apex locator Introduction Teeth are subjected to various traumatic injuries. Trauma can affect the crown, crown-root or root. Root fractures, defined as fractures involving dentin, cementum and pulp, are relatively uncommon among dental traumas. They comprise 0.5 to 7% of the injuries

affecting the permanent dentition. Root fractures are usually classified as involving the apical, middle or coronal third of the root 1, 2 Fracture of the root may be transverse (horizontal), oblique or vertical. In cases of oblique root fracture, coronal segment of pulps of teeth become nonvital with time, while the pulp of apical fragment remains vital. Thus, endodontic therapy up to the fracture line is recommended, leaving the apical root segment untreated 3, 4 Determination of the working length also plays a key role in success of endodontic treatment Traditionally, measurements of

working length have been made by using radiographs with a root canal file in place. However it has been reported that it is difficult to exactly locate the apical constriction radiographically as it is a two dimensional image Radiographs are also influenced by factors such as tooth inclination, position of the X-ray tube and Original Research
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90 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 90 superimposition of anatomical structures among others Electronic apex locators have been widely used clinically for more than forty years as an aid to determine

the working length. The electronic method of working length determination eliminates many of the problems associated with radiographic measurements In cases of oblique factures, the situation encountered by the clinician is more complex; it is difficult to exactly determine the level up to which cleaning and shaping procedures have to be performed. Moreover, in fracture cases determination of working length using radiographs becomes difficult because of angulation of the fracture plane with respect to the root axis The purpose of this study was to determine the accuracy of four electronic apex

locators (Propex II, Root ZX, Ipex, Neosono Co-Pilot) to locate the working length in teeth with simulated oblique root fracture. Materials and Methods 1. Preparation of samples: The root surfaces of the teeth were cleaned with scalers to remove calculus and remnants of periodontal ligament. Teeth (n=30) were placed in 5.2% sodium hypochlorite solution for 24 hours to dissolve any tissue on the root surface. They were then, numbered for identification purposes during the whole procedure. Standard access cavities were prepared with an Endoaccess bur and finished with safety tip tapered diamond

bur under constant water cooling. The patency of the canal was verified using #15 K file and irrigated with a 2.5% sodium hypochlorite solution. 2. Preparation of the oblique notch: An oblique incomplete notch was made on labial surface of root using a 0.4mm diamond disc. The notch was prepared at an angle of approximately 65 to the long axis of tooth at low speed and under constant water cooling, simulating an oblique root fracture (fig 1). The notch was made at a distance of 8mm from the anatomic apex of the root completely exposing the root canal. The palatal portion of the root was left

intact, thus avoiding the complete separation of the root segment. 3. Measurement of true working length with respect to the fracture plane: A thin cement spatula was inserted into the prepared notch. A #25 K file was introduced through the access cavity till it makes a firm contact with spatula (fig 2). A stopper was adjusted to contact the incisal reference point and the working length was measured. To obtain true working length, 0.5mm was subtracted from this measured length. 4. Experimental set up for measurement of electronic working length: Alginate impression material was freshly mixed

and poured into a small plastic container. This acts as an electro conductive medium 9, 10 . Roots of the teeth and lip clip of the apex locator were introduced into the alginate. Roots of the teeth were submerged till the cemento- enamel junction. Root canals were irrigated with saline solution and pulp chambers were dried with cotton pellets. A #25 K file connected to the file clip of the apex locator was inserted slowly inside the canal. The electronic working length was recorded when apex locator indicated that the tip of the file had reached 0.5mm from the fracture RAGHU SRINIVASAN,

KALPANA KANYAL
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91 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 91 line. All measurements were made within two hours of the model being prepared. A total of 120 measurements were recorded, 30 with each apex locator namely (Propex II, Ipex, Root ZX, Neosono Co-pilot). Data was recorded and results were compared with the true working length, allowing a tolerance of 0.5mm and 1mm. Measurements were considered as accurate if it is equal to the true working length or the difference between electronic and true working length was 0.5mm, as acceptable with the

difference of 1mm and non-acceptable if the difference was more than 1mm. Data obtained was subjected to statistical analysis. Analysis of variance (one way ANOVA) was performed to evaluate the differences among the four electronic apex locators (Table 1). Actual difference and Dahlberg method error were considered to evaluate the individual apex locators. Measurements recorded with each apex locator at the 0.5mm and 1mm tolerance were analyzed with chi-square test (Table 2). Results A total of 120 electronic measurements were made, 30 with each EAL (electronic apex locator). All the

measurements were recorded in millimeters (mm) and results obtained with 0.5 and 1mm tolerances are summarized in Table 2. Descriptive statistics for all the apex locators are given in Table 1, 2. From Table 1, it can be seen that according to the ANOVA test, there are no significant differences for true working length among the four apex locators (p= 1.0) and electronic working length among the four apex locators is also statistically similar (p=0.515). Actual difference (Table 1) is lowest for Propex II followed by Root ZX, Ipex and Neosono Co-pilot. Dahlberg method error is lowest for

Propex II (Table1) followed by Root ZX, Ipex, and Neosono Co-pilot. From Table 2 (chi-square test), it can be seen that at a 0.5mm tolerance significant differences are found among the four apex locators (p= 0.004), and at 1mm tolerance no significant differences are found (p= 0.4). Discussion Horizontal or oblique root fractures usually occur in anterior teeth due to traumatic injury. In this clinical situation, it is difficult to determine the exact level up to which cleaning and shaping procedures have to be performed. In this study, as a safety factor to avoid over instrumentation and to

create an apical stop, this limit was considered to be 0.5mm short of the fracture line. Goldberg et al , Shahabang et al 11 suggested that a 1mm tolerance can be considered clinically acceptable. Therefore in our study the performance of the apex locators was evaluated at 1mm also. Results of this study at 0.5 mm tolerance are not in accordance with the study done by Goldberg et al where they found no significant differences at 0.5 mm. At 1mm tolerance, our results are in accordance with their study. The tolerance margin of 1 mm should be considered acceptable, especially in cases of oblique

fractures, where determination of apical limit becomes difficult because of the inclination of the fracture plane with respect to the root axis. EVALUATION OF THE ACCURACY OF FOUR ELECTRONIC APEX LOCATORS - PROPEX II, ROOT ZX, IPEX, NEOSONO CO-PILOT TO DETERMINE THE WORKING LENGTH IN TEETH WITH SIMULATED OBLIQUE ROOT FRACTURE - AN IN VITRO STUDY
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92 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 92 In this study, Propex II (fifth generartion) was found to be more accurate compared to other apex locators. These results are in accordance with the study done

by Plotino et al 12 . The probable reasons could be due to: - The incorporation of latest multi-frequency technology in this apex locator - One important characteristic of Propex II is that calculation is based on the energy of the signal where the other apex locators usually use the amplitude of signal. The manufacturer claims that energy measurement is more precise . On the contrary, Neosono Co-pilot being a fifth generation apex locator underperformed in detection of the oblique root fracture. This finding is in accordance with the results obtained by Chopra et al 13 who evaluated the

accuracy of fifth generation apex locators (Raypex 5 and Neosono Co-pilot). Their results showed that the reliability of electronic apex locators in detecting the apex varies from 80 to 85% for Neosono system and 85 to 90% for the Raypex system. In this study, Root ZX is found to be better than Ipex, a fourth generation apex locator. This finding is similar to those obtained by De Vasconcelos et al 14 , Stober et al 15 . They found that in determining the working length, Root ZX was better than Ipex, though there were no statistically significant differences. The reason could be that fourth

generation apex locators perform well in relatively dry or in partially dried canals 16 , whereas the canals in this study were preirrigated with saline solution. Under the experimental conditions of this in vitro study all the four apex locators (Propex II, Root ZX, Ipex, Neosono Co-pilot), detected the oblique root fractures accurately at 1mm tolerance. Fig 1: Tooth marked prior to making an oblique notch Fig 2: Measurement of true working length using a cement spatula in notch and K file placed in the canal Fig 3: Experimental set up - measurement of electronic working length using an apex

locator RAGHU SRINIVASAN, KALPANA KANYAL
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93 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 93 Table 1: Significance evaluation of apex locators between true working length and electronic working length Apex Locators Propex II Root ZX IPEX Neosono - copilot ANOVA F value P value True Working length 14.901.97 14.901.97 14.901.97 14.901.97 0.000 1.000 Electronic Working Length 14.501.97 14.281.92 13.902.37 13.782.02 0.767 0.515 Actual difference 0.401.24 0.620.63 1.001.04 1.121.03 3.233 0.025* Significance (TWL-EWL) 0.090 <0.001** <0.001**

<0.001** Dahlberg Method error 0.0033 0.0041 0.0173 0.0192 Table 2: Summary of measurements at 0.5 and 1mm tolerance with chi-square test ( ) and p value Tolerance 0.5 1.0 Accuracy Accurate Non-acceptable Total Accurate & Acceptable Non-acceptable Total Propex II 19(63.3%) 11(36.7%) 30 27(90.0%) 3(10.0%) 30 Root Zx 19(63.3%) 11(36.7%) 30 28(93.3%) 2(6.7%) 30 Ipex 13(43.3%) 17(56.7%) 30 25(83.3%) 5(16.7%) 30 Neosono Co-pilot 7(23.3%) 23(76.7%) 30 24(80.0%) 6(20.0%) 30 Chi-square test and p value =13.200 p=0.004** =2.800 p=0.410 Conclusion The following conclusions can be drawn from the present

study: 1. All the electronic apex locators (PropexII, Root ZX, Ipex, Neosono Co-pilot) successfully detected the oblique root fractures. At 1mm tolerance they were more accurate and the results were statistically similar. At 0.5 mm tolerance they were found to be less accurate and statistically significant differences among the four apex locators were found. 2. Propex II was more accurate followed by Root ZX, Ipex and Neosono Co-pilot. 3. It can be concluded that a 1mm tolerance can be considered acceptable, especially in cases of oblique fractures, where radiographic determination of apical

limit becomes difficult. References: 1. Andreason JO. Traumatic injuries of the teeth. 2 nd ed. Copenhagen: Munksgaard; 1981. p. 119. 2. Ingle, Barkland, Baumgartner. Ingles Endodontic. 6 th ed. Hamilton: BC Decker Inc; 2008. p. 1339. 3. Goldberg F, Frajlich S, Kuttler S, Manzur E, Briseno- Marroquin B. The evaluation of four electronic apex locators in teeth with simulated horizontal oblique root fractures. J Endod 2008;34(12):1497-99. 4. Andreason JO, Hjorting- Hansen E. Intralveolar root fractures: radiographic and histologic study of 50 cases. J oral Surg 1967;25:414-26 5. Herrera M,

Abalos C, Planas AJ, Llamas R. Influence of EVALUATION OF THE ACCURACY OF FOUR ELECTRONIC APEX LOCATORS - PROPEX II, ROOT ZX, IPEX, NEOSONO CO-PILOT TO DETERMINE THE WORKING LENGTH IN TEETH WITH SIMULATED OBLIQUE ROOT FRACTURE - AN IN VITRO STUDY
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94 ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY 94 apical constriction diameter on Root ZX apex locator precision. J Endod 2007; 33(8): 995-98. 6. Ozsezer E, Inan U, Aydun U. In vivo evaluation of Propex electronic apex locator. J Endod 2007;33(8):974-77. 7. Palmer MJ, Weine FS, Healey HJ. Position of the

apical foramen in relation to endondontic therapy. J Can Dent Assoc 1971;37: 305-8 8. Ebrahim AK, Wadachi R, Suda H. Accuracy of three different electronic apex locators in detecting simulated horizontal and vertical root fractures. Aust Endod J 2006;32:64-69. 9. 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;37:174-77. 10. Vatkar NA, Sathe S, Hegde V. In vitro evaluation of the efficacy of five apex locators. J Endodon 2008;20(2):36-42. 11. Shabahang S, Goon W,

Gluskin AH. An in vivo evaluation of Root ZX electronic apex locator. J Endod 1996;22(11):616-18. 12. Plotino G, Grande NM, Brigante L, Lesti B, Somma F. Ex vivo accuracy of three electronic apex locators: Root ZX, Element Diagnostic Unit Apex Locator and Propex. Int Endod J 2006;39:408-14.. 13. Chopra V, Grover S, Prasad SD. In vitro evaluation of two electronic apex locators. J Conserv Dent 2008;11(2):82-85. 14. De Vasconcelos BC, Do Vale TM, De Menezes AST, Pinheiro- Junior EC, Vivacqua-Gomes N, Bernandes RA et al. An ex vivo comparison of root canal length determination by three electronic

apex locators at positions short of the apical foramen. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e57-e61. 15. Stober EK, Duran-Sindreu F, Mercade M, Vera J, Bueno R, Roig M. An evaluation of Root ZX and Ipex apex locators: An in vivo study. J Endod 2011;37(5):608-10. 16. Dimitrov S, Roshkev D. Sixth generation Adaptive apex locator. J IMAB-Annual Proceeding 2009;book 2:75-78. RAGHU SRINIVASAN, KALPANA KANYAL