Radiographic Criteria for Differential Diagnosis Between Vertical Root Fracture and Apical Periodontitis in Single-Rooted Endodontically Treated Premolars Using Cone-Beam Computed Tomography

INTRODUCTION

This study explores the differences between the patterns of bone defects associated with vertical root fracture (VRF) and apical periodontitis (AP) in single-rooted endodontically treated premolars (SRETPs) based on cone-beam computed tomography (CBCT) data.

METHODS

Eighty-four SRETPs were extracted and categorized into the VRF and AP groups. On preoperative CBCT images, the location of bone defects according to the root thirds in buccolingual and mesiodistal directions across the study groups were compared.

RESULTS

The majority of bone defects in the VRF group were longitudinal and combined, involving more than one root thirds in buccolingual and mesiodistal directions simultaneously. A uniform approach to comparing bone defects using the sites of periradicular area with bone loss as a comparison unit was developed. In the VRF group, bone loss sites in the middle and coronal thirds were detected more often and were located mainly buccolingually compared with the AP group (P < .001).

CONCLUSION

Bone defects in the middle or middle and coronal root thirds in the buccolingual direction may be potential radiographic signs useful in differentiating between VRF and AP in SRETPs. The introduction of the uniform approach to assessment of bone loss patterns will give practitioners a single simple tool and improve the quality of endodontic treatment.

Applying the American Association of Endodontists and American Academy of Oral and Maxillofacial Radiology guidelines for cone-beam computed tomography prescription: Impact on endodontic clinical decisions

BACKGROUND

The American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) developed guidelines for the prescription of cone-beam computed tomographic (CBCT) imaging. The impact of appropriately prescribed CBCT imaging on endodontic diagnosis and treatment (Tx) decisions was examined.

METHODS

The clinical databases at the School of Dentistry at the University of California, Los Angeles, Los Angeles, California, were queried to identify patients referred for CBCT imaging from the postgraduate endodontic clinic over a consecutive 36-month period. Primary and secondary indications for CBCT imaging were recorded. Pre-CBCT uncertainty in diagnosis, Tx of the teeth in question, and post-CBCT changes to the diagnosis and Tx plan were recorded.

RESULTS

CBCT imaging was prescribed for 12% of patients. A total of 442 scans were prescribed to evaluate 526 teeth. Molars accounted for 51% of teeth examined. Overall, CBCT effected a change in periapical diagnosis (21%) and in the Tx plan (69%). The 5 most frequent primary indications for CBCT imaging were, in order, AAE-AAOMR recommendations 7, 9, 2, 12, and 6. The impact of these recommendations on Tx decisions varied from 48% through 93%.

CONCLUSIONS

This study validates the use of the AAE-AAOMR guidelines for prescribing CBCT imaging for endodontic evaluations. CBCT imaging contributed predominantly to Tx decisions rather than diagnostic determinations.

PRACTICAL IMPLICATIONS

This study validates AAE-AAOMR case selection guidelines for CBCT imaging and shows a positive impact of prescription imaging on endodontic decision making.

Effect of different intracanal posts and exposure parameters on detection of vertical root fractures by cone-beam computed tomography

This study evaluated the effect of different amperage values and voxel sizes of two CBCT scanners on VRF detection in the presence of different intracanal posts. After post-space preparation, VRFs were induced in half of the samples of 20 maxillary premolars. Five different intracanal posts were passively placed in each root canal. Samples were scanned using CS 9300 and Cranex3D with two different voxel sizes and amperage setting in each unit. The diagnostic sensitivity, specificity and accuracy were compared using the Mann-Whitney and Kruskal-Wallis tests (α = 0.05). Changes in amperage and voxel size did not affect the detection of VRFs (p ⟩ 0.05). The VRF detection accuracy was the highest in fibreglass and the lowest in nickel-chromium group. Changes in amperage and voxel size within assessed values do not seem to influence the detection of VRF whereas different intracanal post-materials have significant effect on VRF detection.

Risk factors for and clinical presentations indicative of vertical root fracture in endodontically treated teeth - a systematic review and meta-analysis

INTRODUCTION

The aim of this study was to identify specific clinical signs or symptoms and potential risk factors which are most likely associated with the presence of a vertical root fracture (VRF) in endodontically treated teeth (ETT).

METHODS

Electronic databases (MEDLINE via PubMed, EMBASE via Ovid, Scopus, and Web of Science) were searched by two reviewers in October 2022 for clinical studies, in which at least either the clinical presentation or potential risk factors associated with a VRF were assessed. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of odds ratios (ORs) were performed separately for several signs or symptoms and risk factors.

RESULTS

Fourteen sources reporting on 2,875 teeth (489 with VRF and 2,388 without VRF) were included in the meta-analyses. Regarding the clinical presentation, the presence of sinus tracts (OR=4.87; 95%-CI: 1.58-15.0), increased periodontal probing depths (OR=13.24; 95%-CI: 5.44-32.22), swelling/abscess (OR=2.86; 95%-CI: 1.74-4.70), and tenderness to percussion (OR=1.74; 95% CI: 1.18-2.61) were significantly associated with the presence of a VRF (P_adj. value<.05). None of the assessed risk factors (sex, type of teeth, tooth location, posts, indirect restoration, apical extension of the root canal filling), were found to be significantly associated with the presence of a VRF (P_adj. value>.05).

CONCLUSIONS

Four clinical presentations were identified to be the most significant signs or symptoms for a VRF in ETT: presence of sinus tracts, increased probing depths, swelling/abscess, tenderness to percussion. None of the assessed risk factors pointed out to be significantly associated with a VRF.

REGISTRATION

CRD42022354108 (PROSPERO).

Diagnostic efficacy of cone-beam computed tomography for detection of vertical root fractures in endodontically treated teeth: a systematic review

BACKGROUND

Vertical root fractures (VRFs) sometimes occur in endodontically treated teeth. They have a difficult diagnosis and a dismal result. The objective of this review was to evaluate the diagnostic performance of cone-beam computed tomography (CBCT) for detecting VRFs in teeth that had undergone endodontic treatment.

METHODS

Literature was reviewed from Web of Science, PubMed, Cochrane Review, SCOPUS, and Embase databases between 2000 and 2022. The searched keywords included "endodontically treated teeth," "cone-beam computed tomography," "CBCT," "tooth fracture," "vertical root fracture," "VRF," "accuracy," "sensitivity," and "specificity." Only articles in the English language were included. The final analysis included 20 papers that satisfied the eligibility requirements.

RESULTS

The overall mean ± SD values (%) for the diagnostic sensitivity and specificity of CBCT for detection of VRFs in endodontically treated teeth in the presence of root-filling materials without an intracanal post were 71.50 ± 22.19 and 75.64 ± 19.41, respectively. The overall mean (SD) value (%) for the sensitivity of CBCT for the detection of VRFs in the presence of root-filling materials and intracanal posts was 72.76 (18.73), while the mean (SD) specificity was 75.44 (18.26). The accuracy of CBCT (mean ± SD) was 78.47 ± 17.19% and 74.02 ± 10.64%, respectively, for teeth without intracanal posts and those with posts.

CONCLUSIONS

Further clinical research is needed to validate the optimum efficiency of CBCT as a diagnostic technique for detecting VRFs in teeth that have had endodontic treatment, given the low sensitivity, significant heterogeneity of studies, and lack of in-vivo studies on the subject.

CBCT in contemporary endodontics

Cone-beam computed tomography (CBCT) is a three-dimensional imaging modality which can aid endodontic diagnosis and treatment planning. While there are guidelines available describing the indications, there are divergent philosophies on when this technology should be applied in clinical practice. This paper reviews the applications of CBCT including the clinical relevance of parameters which can be assessed, highlights the limitations of this technology, and provides guidance on how to maximise its clinical utility.

Detecting Vertical Root Fractures Using Modified Methylene Blue Dye: A Preliminary In Vitro Study

Diagnostically, vertical root fractures (VRFs) can be a frustrating experience for the dentist. Misdiagnosis could result in significant time and effort losses involved in erroneously intervening endodontically and/or periodontally. Certainly, diagnosing VRFs is often very difficult, and diagnoses based on speculations have led to the extraction of many salvageable teeth. This study was conducted in the radiology unit of College of Dentistry, Prince Sattam bin Abdulaziz University, between December 2021 and June 2022 to evaluate the ability to detect VRFs following the use of a novel radio-opaque dye using periapical radiographs (PARs) and cone-beam computed tomography (CBCT). After carefully inducing VRFs on extracted, single-rooted, virgin premolars (n = 26), they were assigned to control (n = 2) and experimental groups (n = 24). The fracture site of the tooth in the control group received methylene blue dye, whereas the experimental group received a novel dye. Two differently angled PARs were obtained for all the teeth, followed by a CBCT image. Three blinded investigators participated in scoring a Likert scale form with a set of questions. Inter-/intra-examiner reliability showed excellent consistency using Cronbach's alpha test. The Z-test revealed CBCT and PAR to be equally adept at detecting VRFs, with the mean values showing no statistically significant differences. The extent of the VRFs and dye penetration were significantly better when angled radiographs and axial view CBCT were evaluated. Within the limitations of this study, the dye tested showed promising initial results as an aid in radiographically detecting VRFs. The use of such minimally invasive methods is critically needed for diagnosing and managing VRFs. However, further testing should be performed prior to its clinical use.

Influence of the technical parameters of CBCT image acquisition on vertical root fracture diagnosis: a systematic review and meta-analysis

OBJECTIVES

To evaluate the influence of image acquisition parameters (voxel, FOV, kVp, mA) on the accuracy of cone-beam computed tomography (CBCT) in detecting vertical root fracture (VRF).

MATERIAL AND METHODS

Searches were performed in 6 main databases and the gray literature, without restrictions of language or date. Observational clinical studies (OCS) and in vitro-extracted teeth (IV) studies were considered eligible for inclusion when investigating the accuracy (sensitivity, specificity) of CBCT in detecting VRF in human teeth. The risk of bias was assessed using QUADAS-2, and a meta-analysis was performed using Review Manager v5.4 software and Jamovi software v1.6.

RESULTS

A total of 60 out of 132 articles was included after fulfilling the eligibility criteria. Of these, 54 were IV studies while 6 were OCS. In the IV studies, it was seen that smaller FOV sizes tended to present higher accuracy values. The meta-analysis of the 6 OCS showed that the overall sensitivity and specificity values for 0.08 mm and 0.1 mm voxels were greater (0.84 and 0.79, respectively) than the sensitivity and specificity values for 0.125 mm and 0.2 mm voxels (0.70 and 0.55, respectively).

CONCLUSIONS

Despite the uncertain risk of bias found for the IV and OCS studies, smaller voxel and FOV sizes seem to provide more accurate VRF detection values when using CBCT.

CLINICAL RELEVANCE

This information is crucial for supporting the clinician when prescribing CBCT in cases of a clinical suspicion of VRF, and contributes to the personalization of the CBCT prescription, thereby ensuring greater accuracy in the VRF diagnosis. Registration This protocol was registered at the PROSPERO database (International Prospective Register of Systematic Review) under registration number CRD42020210118.

Vertical root fractures in root treated teeth-current status and future trends

Vertical root fracture (VRF) is a common reason for the extraction of root filled teeth. The accurate diagnosis of VRF may be challenging due to the absence of clinical signs, whilst conventional radiographic assessment is often inconclusive. However, an understanding of the aetiology of VRFs, and more importantly, the key predisposing factors, is crucial in identifying teeth that may be susceptible. Thorough clinical examination with magnification and co-axial lighting is essential in identifying VRFs, and although CBCT is unable to reliably detect VRFs per se, the pattern of bone loss typically associated with VRF can be fully appreciated, and therefore, increases the probability of correct diagnosis and management. The prevalence of VRFs in root filled teeth is significantly greater than in teeth with vital pulps, demonstrating that the combination of loss of structural integrity, presence of pre-existing fractures and biochemical effects of loss of vitality, are highly relevant. Careful assessment of the occlusal scheme, presence of deflective contacts and identification of parafunctional habits is imperative in both preventing and managing VRFs. Furthermore, anatomical factors such as root canal morphology, may predispose certain teeth to VRF. The influence of access cavity design and root canal instrumentation protocols should be considered although the impact of these on the fracture resistance of root filled teeth is not clearly validated. The post-endodontic restoration of root filled teeth should be expedient and considerate to the residual tooth structure. Posts should be placed 'passively' and excessive 'post-space' preparation should be avoided. This narrative review aims to present the aetiology, potential predisposing factors, histopathology, diagnosis and management of VRF and present perspectives for future research. Currently, there are limited options other than extraction for the management of VRF, although root resection may be considered in multi-rooted teeth. Innovative techniques to 'repair' VRFs using both orthograde and surgical approaches require further research and validation. The prevention of VRFs is critical; identifying susceptible teeth, utilizing conservative endodontic procedures, together with expedient and appropriate post-endodontic restorative procedures is paramount to reducing the incidence of terminal VRFs.

Smartphone use for tomographic evaluation: application in endodontic diagnosis

INTRODUCTION

Portable equipment that allows quick exchanges of information, such as smartphones, is increasingly important in Dentistry. Thus, they have become frequently used, with the potential to contribute to the tomographic evaluation. This study aimed to evaluate the accuracy of smartphone applications for diagnosing the root canal system (RCS) and measuring the root canal length.

METHODS

DICOM files of 92 lower incisor teeth were evaluated by two trained and calibrated examiners using the CS 3D Imaging software and two smartphone applications (DroidRender and Horos Mobile). The RCS was assessed according to Vertucci's classification, and the tooth length was measured using linear cusp-apex measurements. The diagnostic reference standard was obtained by the mode and the mean of the evaluations made by three experienced examiners using the CS 3D Imaging software. The diagnostic performance of RCS was evaluated using sensitivity (Se), specificity (Sp), and overall accuracy (Ac). The Bland-Altman analysis was used to assess the agreement of linear measurements.

RESULTS

The diagnostic tests showed similar performance between the smartphone applications (DroidRender: Se = 1.00; Sp = 0.95; Ac = 0.97; Horos: Se = 0.95; Sp = 0.94; Ac = 0.95) and the computer software (Se = 0.97 - 0.95; Sp = 0.93 - 0.96; Ac = 0.95 - 0.96). The smartphone applications showed discrepancies greater than 1.0 mm for the dental lengths, which may signal relevant differences in some clinical situations.

CONCLUSION

Smartphone applications offered similar diagnostic performance in comparison to the computer software for the RCS evaluation.

A Critical Review of the Differential Diagnosis of Root Fracture Line in CBCT scans

The objective of this critical review of literature is to discuss relevant clinical factors associated with root fractures (RF) visualized by using a new CBCT software. RF constitutes a common occurrence and a challenge in clinical practice, in which the diagnosis becomes essential for the definition of rapid and precise decision-making. The characterization of RF may involve different aspects, such as orientation of the fracture line (horizontal, vertical, oblique), root position of the fracture (cervical, middle, apical third), fracture's coronal-radicular position (coronary, coronal-radicular, radicular), continuity of the fracture (crack, incomplete fracture, complete), bone extension of the fracture (supraosseous, bone level, infraosseous fracture). Imaging examinations have been routinely used to aid in the RF diagnosis. Even with high-resolution cone-beam computed tomography (CBCT) scans, many doubts often remain about the diagnostic outcome. Many interferences in the analysis of image quality to determine the diagnosis are identified, such as the sharpness, the noise, light and dark artifacts, among others. The professional's knowledge is essential for identifying the different patterns of fracture lines and their repercussions on adjacent bone tissues, as well as for the analysis of artifacts that may hide or show similarities to fracture lines. Fractures lines and root fractures that may be associated with phantom conditions that mimic fractures should be carefully analyzed. CBCT is the exam indicated to identify a root fracture. It is also added to the success of the diagnosis that the professional has scientific knowledge, training and mastery of advanced CBCT software.

Comparison between periapical radiography and cone beam computed tomography for the diagnosis of anterior maxillary trauma in children and adolescents

BACKGROUND/AIMS

Under-estimating the damage caused by trauma to the dental structures may delay treatment. Timely and accurate diagnosis remains challenging in clinical practice. Radiography is an important modality for the diagnosis of traumatic injuries. The aim of this study was to compare the efficacy of periapical radiography and cone beam computed tomography for the diagnosis of trauma to the anterior maxillary dentoalveolar region in children and adolescents.

MATERIAL AND METHODS

Images of patients who underwent both periapical radiography and cone beam computed tomography simultaneously because of trauma to the anterior maxillary region between January 2016 and January 2020 were analyzed retrospectively. Pairwise comparison between the receiver operating characteristic curves was performed to statistically compare the two methods for the diagnosis of crown fractures, root fractures, alveolar bone fractures and luxations, tooth resorption, and periapical radiolucencies.

RESULTS

A total of 190 patients met the inclusion criteria. There were 120 (63.2%) males and 70 (36.8%) females, with a mean age of 11.1 years (range: 6-17 years). A crown fracture was observed in 144 teeth, while a root fracture was observed in 71 teeth. Alveolar fracture and luxation were observed in 44 incisors. During follow-up, tooth resorption and periapical radiolucencies were observed in 25 and 33 teeth, respectively. Pairwise receiver operating characteristic curve analysis revealed that cone beam computed tomography was significantly superior to periapical radiography for the diagnosis of root fractures, alveolar fractures and luxations, and tooth resorption (p < .05). However, no significant differences were found for the diagnosis of crown fractures and periapical radiolucencies (p > .05).

CONCLUSIONS

Cone beam computed tomography in the low-dose mode was better for diagnosing root and bone fractures and resorption, but no different to periapical radiographs for crown fractures and periapical radiolucencies in pediatric patients.

In vivo detection of vertical root fractures in endodontically treated teeth: Accuracy of cone-beam computed tomography and assessment of potential predictor variables

Background

This study aimed: (a) to determine the diagnostic performance of cone-beam computed tomography (CBCT) for detection of vertical root fractures (VRFs); (b) to evaluate the predictive value of diagnostic criteria regarding the definition of VRFs; and (c) to examine the robustness of the association of patient-, tooth-, and treatment-related variables with VRFs.

Material and Methods

130 root-filled teeth with signs/symptoms of VRFs underwent clinical and CBCT assessments. Definite diagnosis of VRF was confirmed by endodontic microsurgical (EMS) exploration. Determination of diagnostic performance of CBCT was based on standard algorithms derived from two-way contingency table analysis. Predictive value of diagnostic criteria and the association between predictor variables with VRFs were analyzed using logistic regression models.

Results

VRFs were detected during EMS in 50% of the teeth. Based on the finding of fracture lines on CBCT scans, sensitivity, specificity, and accuracy were 86.2%, 13.8%, and 50%, respectively. Teeth having more than three diagnostic criteria present had significant higher odds for VRF diagnosis. After logistic regression analysis, parafunctional habits, one-canal roots, excessive root canal enlargement, and absence of intra-radicular posts remained as robust predictor variables of VRFs.

Conclusions

Although the sensitivity of CBCT for VRFs detection is high, the risk of false-positive results related to its low specificity makes that all suspected cases must be confirmed by surgical exploration. VRFs cannot be reliably diagnosed by isolated clinical signs/symptoms; instead those teeth possessing more than three diagnostic criteria might be considered practically pathognomonic. The parafunctional habits, one-canal roots, excessive root canal enlargement, and the absence of intra-radicular posts may act strongly/independently for the occurrence of VRFs in endodontically treated teeth.

Key words:Cone-beam computed tomography, diagnostic accuracy, diagnostic surgery, predictor variables, root canal treatment, vertical root fracture.

Assessment of true vertical root fracture line in endodontically treated teeth using a new subtraction software - A Micro-CT and CBCT study

This study aimed to find true facture lines in endodontically treated teeth on CBCT images using digital subtraction and to evaluate the influence of width of facture lines in the diagnosis. Thirty-two endodontically treated teeth with vertical root fractures (VRFs) from 30 patients were included in this study. The CBCT images of the patients and the micro-CT images of extracted teeth were imported into our digital subtraction software to distinguish the true facture lines from the streak artefacts. Of them, 23(71.87%) teeth did not present true fracture lines on the CBCT images (CBCT negative), and 9 (28.13%) teeth presented true fracture lines on the CBCT images (CBCT positive). The width of the facture lines was significantly different between these two groups (P < 0.05). To summarise, for in vivo endodontically treated teeth with subtle VRFs, many true fractures lines could not be demonstrated on CBCT images and wider fractures could be better distinguished.

Treatment of an Endo-Perio Lesion with Ozone Gas in a Patient with Aggressive Periodontitis: A Clinical Case Report and Literature Review

The pulp and periodontium have obvious relationships that have been described in many studies. Pulp infections may affect periodontal tissues and vice versa. Teeth with endo-perio lesions have a worse prognosis than isolated endodontic or periodontal lesions. Elimination of endodontic and periodontal infections is essential for successful treatment, so co-operation between endodontists and periodontists is necessary. In this clinical case, a 44-year-old male presented with primary periodontal disease with secondary endodontic involvement in his lower right canine because of aggressive periodontitis. There was 10 mm of clinical attachment loss and 8 mm periodontal pocket mesial from the tooth and bone radiolucency periapical and lateral from the root. Periodontal therapy was followed by endodontic treatment. Periodontal therapy included root scaling and planing, treatment of the periodontal pocket with ozone gas, systemic antibiotics, oral hygiene instructions, and chlorhexidine rinsing. Endodontic therapy included root canal instrumentation with rotary endodontic files, irrigation, root canal treatment with ozone gas, and obturation with lateral compaction. Radiographs at a 6-month follow-up appointment showed complete healing of the periapical lesion and alveolar bone lateral to the root. Using an interdisciplinary approach to treat endo-perio lesions provides favorable clinical outcomes. Ozone therapy is beneficial for the successful treatment of endo-perio lesions with narrow periodontal pockets in patients with aggressive periodontitis and poor prognosis.

Differences in the corono-apical location of sinus tracts and buccal cortical bone defects between vertically root-fractured and non-root-fractured teeth based on periradicular microsurgery

This retrospective study aimed to investigate whether the corono-apical location of sinus tracts differs according to the presence/location of vertical root fracture (VRF) in microsurgically treated root-filled teeth. The cases included were (1) anterior and premolar teeth without a preoperative diagnosis of VRF, (2) those with a periodontal probing depth of ≤3 mm, and (3) those for which preoperative cone-beam computed tomography (CBCT) scans and intraoperative video records were available. VRF was diagnosed intraoperatively. The locations of buccal cortical bone defects and fracture lines were categorized on video images, and the corono-apical sinus tract locations were determined by superimposing video images onto volume-rendered CBCT images. Eleven of the 78 teeth investigated had VRF, and there was no significant difference in the incidence of sinus tracts between vertically fractured and non-fractured teeth (Mann-Whitney U-test, P > 0.05). The location of the sinus tract was significantly more coronal in vertically fractured than in non-fractured teeth (Mann-Whitney U-test, P < 0.0001). The location of sinus tracts was high correlated with cortical bone defects (Spearman's correlation, P < 0.0001). In microsurgically treated anterior and premolar teeth with a normal probing depth, sinus tracts were located more coronally in vertically fractured than in non-fractured teeth, and were highly correlated with the location of cortical bone defects.

Diagnosis of root fractures using cone-beam computed tomography: difference of vertical and horizontal root fracture

OBJECTIVES

The aim of this study was to investigate the occurrence of vertical and horizontal root fractures using cone-beam computed tomography (CBCT).

METHODS

We reviewed the CBCT images of 51 patients who were examined by CBCT for the diagnosis of root fracture. The occurrences of vertical and horizontal root fractures were investigated concerning the pulpal vitality and the kind of tooth, and analyzed by cross-tabulation. The fracture direction of vertical root fracture and the fracture angle were also investigated, and analyzed by cross-tabulation and Kruskal-Wallis test, respectively.

RESULTS

The occurrence of vertical and horizontal root fractures was statistically significantly different between vital tooth and non-vital tooth (p = 0.044). The occurrence of vertical and horizontal root fractures was also different among anterior, premolar, and molar teeth (p = 0.004). The kind of tooth on traumatized tooth was only anterior teeth and the number was larger on horizontal root fracture. The occurrence of vertical and horizontal root fractures on non-traumatized tooth was different among the kind of tooth (p = 0.007), and the number of vertical root fracture was larger than that of horizontal root fracture on premolar teeth. Fracture direction was not different, but the fracture angle was different among the kind of tooth on vertical root fracture (p = 0.027).

CONCLUSIONS

The results suggested that the number of vertical root fracture was larger on non-vital tooth and that of horizontal root fracture was larger on vital tooth. The number of vertical root fracture was larger on premolar teeth.

Digital subtraction radiography in detection of vertical root fractures: accuracy evaluation for root canal filling, fracture orientation and width variables. An ex-vivo study

OBJECTIVE

Ex-vivo evaluation of the detectability of vertical root fractures (VRFs) using digital subtraction radiography (DSR) and conventional digital periapical radiography (CDPR); investigation of the effect of root canal filling, x-ray angulation, and thickness of the VRF in the diagnostic accuracy.

MATERIALS AND METHODS

Sixty root canals were mechanically prepared and radiographed either with a gutta-percha root canal filling or without, at 0^o and ± 10^o. VRFs were introduced with a universal testing machine. The width and angulation of the fracture line with the radiographic beam were calculated. DSR was performed comparing radiographs obtained prior to and after the VRF induction. Five examiners evaluated the resultant images and analysis was performed using receiver operator characteristic (ROC) statistics and binary logistic regression tests.

RESULTS

No significant differences in sensitivity, specificity, and the areas under the ROC curves (AUC) between the CDPR and DSR were detected (p > 0.05), except for root canal filled teeth where the AUC for DSR was higher (p < 0.05). Using DSR, a VRF was 1.3 times more likely to be diagnosed [95% confidence intervals (CI): 1.045-1.59; p = 0.018]. A correct diagnosis was 2.399 times more likely to occur in non-filled teeth regardless of the radiographic technique (95% CI 1.940-2.965; p = 0). The regression coefficients were positive for width and negative for angle.

CONCLUSIONS

DSR showed a better diagnostic accuracy of VRFs compared with CDPR, in single root canal filled teeth. The angulation, the width, and the presence of a root canal filling affected the diagnostic potential.

CLINICAL RELEVANCE

DSR is a cost- and time-effective imaging technique that could contribute in early diagnosis of VRFs.