Comparison of conventional radiography with cone beam computed tomography for detection of vertical root fractures: an in vitro study

Is cone-beam computed tomography more accurate than periapical radiography for detection of vertical root fractures? A systematic review and meta-analysis

BACKGROUND

This study aimed to conduct a systematic review and meta-analysis to summarize the available evidence comparing the diagnostic accuracy of periapical radiography (PA) and cone-beam computed tomography (CBCT) for detection of vertical root fractures (VRFs).

METHODS

A search was conducted in PubMed, Scopus, and Web of Science for articles published regarding all types of human teeth. Data were analyzed by Comprehensive Meta-Analysis statistical software V3 software program. The I2 statistic was applied to analyze heterogeneity among the studies.

RESULTS

Twenty-three articles met the criteria for inclusion in the systematic review and 16 for the meta-analysis. The sensitivity and specificity for detection of VRFs were calculated to be 0.51 and 0.87, respectively for PA radiography, and 0.70 and 0.84, respectively for CBCT.

CONCLUSIONS

The sensitivity of CBCT was higher than PA radiography; however, difference between the specificity of the two modalities was not statistically significant.

Developing evidence-based clinical imaging guidelines for the diagnosis of vertically fractured teeth

OBJECTIVES

This study aimed to develop an evidence-based clinical imaging guideline for teeth suspected with vertical root fractures.

METHODS

An adaptation methodology based on the Korean Clinical Imaging Guidelines (K-CIG) was used in the guideline development process. After searching for guidelines using major databases such as Ovid-Medline, Elsevier-Embase, National Guideline Clearinghouse, and Guideline International Network, as well as domestic databases such as KoreaMed, KMbase, and KoMGI, two reviewers analyzed the retrieved articles. The retrieved articles were included in this review using well-established inclusion criteria.

RESULTS

Twenty articles were identified through an online search, of which three were selected for guideline development. Based on these three guidelines, this study developed specific recommendations concerning the optimal imaging modality for diagnosing teeth suspected of vertical root fractures.

CONCLUSIONS

Periapical radiography is the preferred method for assessing teeth with mastication-related pain and suspected vertical root fractures. However, if intraoral radiographs do not provide sufficient information about root fractures, a small FOV CBCT may be considered. However, the use of CBCT in endodontically treated teeth is significantly constrained by the presence of artificial shading.

Cone-Beam Computed Tomography Assessment of Prevalence of Procedural Errors in Maxillary Posterior Teeth

A range of procedural errors can occur when performing endodontic treatment on posterior teeth. These errors may decrease the success rate in endodontic practice. This study assessed the prevalence of procedural errors and the quality of endodontic treatments in maxillary molars and premolars using cone-beam computed tomography (CBCT). CBCT scans from two private radiology centers were assessed retrospectively to ensure the same calculated sample size of 327 teeth for each of the four maxillary posterior tooth types (a total of 1,308 endodontically treated teeth). Image sets were evaluated for procedural errors categorized as follows: obturation length (overfilling or underfilling by >2 mm short of the root apex), missed canals, perforations, strip perforations (with extrusion of material into the furcation area), separated instruments in the root canal space, and root fracture. Data were analyzed with SPSS version 20 (SPSS Inc., Chicago, IL, USA), and frequency data was assessed using the Monte Carlo test at the 0.05 level of significance. The procedural errors most commonly reported in the present study were from most frequent to least frequent: underfilled canals (50.0%), missed canals (27.5%), overfilled canals (12.5%), apical perforations (5.0%), separated instruments (3.1%), and root fractures (1.9%). No strip perforations (with extrusion of material into the furcation area) were seen in the study (0%). Underfilled and missed root canals were the most frequent procedural errors identified in the present study. These findings underline the importance of more consideration of critical working length management during all stages of root canal treatment, greater awareness of root canal anatomy, and the use of imaging and diagnostic devices that enhance the ability to identify and treat root canals both safely and effectively.

Artificial Intelligence and Its Application in Endodontics: A Review

AIM AND BACKGROUND

Artificial intelligence (AI) since it was introduced into dentistry, has become an important and valuable tool in many fields. It was applied in different specialties with different uses, for example, in diagnosis of oral cancer, periodontal disease and dental caries, and in the treatment planning and predicting the outcome of orthognathic surgeries. The aim of this comprehensive review is to report on the application and performance of AI models designed for application in the field of endodontics.

MATERIALS AND METHODS

PubMed, Web of Science, and Google Scholar were searched to collect the most relevant articles using terms, such as AI, endodontics, and dentistry. This review included 56 papers related to AI and its application in endodontics.

RESULT

The applications of AI were in detecting and diagnosing periapical lesions, assessing root fractures, working length determination, prediction for postoperative pain, studying root canal anatomy and decision-making in endodontics for retreatment. The accuracy of AI in performing these tasks can reach up to 90%.

CONCLUSION

Artificial intelligence has valuable applications in the field of modern endodontics with promising results. Larger and multicenter data sets can give external validity to the AI models.

CLINICAL SIGNIFICANCE

In the field of dentistry, AI models are specifically crafted to contribute to the diagnosis of oral diseases, ranging from common issues such as dental caries to more complex conditions like periodontal diseases and oral cancer. AI models can help in diagnosis, treatment planning, and in patient management in endodontics. Along with the modern tools like cone-beam computed tomography (CBCT), AI can be a valuable aid to the clinician. How to cite this article: Ahmed ZH, Almuharib AM, Abdulkarim AA, et al. Artificial Intelligence and Its Application in Endodontics: A Review. J Contemp Dent Pract 2023;24(11):912-917.

Endodontic Orthograde Retreatments: Challenges and Solutions

Endodontic orthograde retreatments are considered one of the possible treatment options in case of post-treatment diseases considering the promising results present in the literature. Despite this, a plethora of articles have been published on this topic, and drawing conclusions could be challenging. For this reason, this review aims to summarize the crucial points on each aspect of non-surgical endodontic retreatments, discussing and comparing the current protocols, techniques, materials, and indications. Taking into consideration data from the literature, in terms of diagnosis, CBCT should be considered the first choice, since it can thoroughly affect the diagnosis and treatment plan. Regarding the procedural phases, some conclusions can be drawn: when present, coronal restoration materials such as crowns, partial prostheses, post, and core should be removed; the use of magnification devices, ultrasonic instruments, and an in-depth interpretation of radiographic images with both 2D and 3D images are strongly recommended during the orifice location; additional protocols such as irrigants activation, ultrasonic cleaning, and rotary or reciprocating instrumentation of treated canals are strongly recommended for filling materials removal and to achieve a high-quality chemo-mechanical disinfection; perforations should be treated as soon as possible, and the material of choice to treat them is the MTA or other calcium-silicate-based repair materials; the presence of ledges does not intrinsically reduce the success rate of RCRts if properly managed; in case of instrument fragments, their removal should be considered as the first treatment option, however many variables should be considered to select the proper technique or consider the option of bypassing.

Influence of voxel size and filter type on detecting vertical root fracture using cone-beam computed tomography

Vertical root fractures (VRFs) can start at any level of the root and progress longitudinally to the coronal attachment. This study aimed to investigate the effects of different exposure parameters used when obtaining CBCT scans in detecting simulated VRFs. Hence, 80 intact human mandibular single-rooted pre-molar teeth without root fractures were included in the study. No statistically significant difference was found between the filters in terms of VRF detection in the group with the roots with only root canal filling (Groups 1 and 5); however, 100 voxels were found to be more successful in terms of VRF detection than other voxel sizes. Results of this study suggest that using lower voxel sizes leads to an accurate diagnosis of vertical root fracture, in addition, our results revealed that using AR filters did not improve the diagnostic accuracy in detecting VRFs.

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.

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.

Evaluation of the Diagnostic and Prognostic Accuracy of Artificial Intelligence in Endodontic Dentistry: A Comprehensive Review of Literature

Aim

This comprehensive review is aimed at evaluating the diagnostic and prognostic accuracy of artificial intelligence in endodontic dentistry.

Introduction

Artificial intelligence (AI) is a relatively new technology that has widespread use in dentistry. The AI technologies have primarily been used in dentistry to diagnose dental diseases, plan treatment, make clinical decisions, and predict the prognosis. AI models like convolutional neural networks (CNN) and artificial neural networks (ANN) have been used in endodontics to study root canal system anatomy, determine working length measurements, detect periapical lesions and root fractures, predict the success of retreatment procedures, and predict the viability of dental pulp stem cells. Methodology. The literature was searched in electronic databases such as Google Scholar, Medline, PubMed, Embase, Web of Science, and Scopus, published over the last four decades (January 1980 to September 15, 2021) by using keywords such as artificial intelligence, machine learning, deep learning, application, endodontics, and dentistry.

Results

The preliminary search yielded 2560 articles relevant enough to the paper's purpose. A total of 88 articles met the eligibility criteria. The majority of research on AI application in endodontics has concentrated on tracing apical foramen, verifying the working length, projection of periapical pathologies, root morphologies, and retreatment predictions and discovering the vertical root fractures.

Conclusion

In endodontics, AI displayed accuracy in terms of diagnostic and prognostic evaluations. The use of AI can help enhance the treatment plan, which in turn can lead to an increase in the success rate of endodontic treatment outcomes. The AI is used extensively in endodontics and could help in clinical applications, such as detecting root fractures, periapical pathologies, determining working length, tracing apical foramen, the morphology of root, and disease prediction.

CBCT in orthodontics: a systematic review on justification of CBCT in a paediatric population prior to orthodontic treatment

BACKGROUND

Taking into account radiation doses, safety, and protection, we highlighted the features in which cone-beam computed tomography (CBCT) can offer an advantage compared to the conventional two-dimensional imaging in paediatric dentistry before orthodontic treatment.

OBJECTIVE

The aim of this article was to conduct a systematic review to assess the diagnostic efficacy of CBCT in the paediatric population at a pre-orthodontic phase.

SEARCH METHODS

MEDLINE via PubMed was searched to identify all peer-reviewed articles potentially relevant to the review until 1 July 2018. Relevant publications were selected by two reviewers independently.

SELECTION CRITERIA

The literature selection for this systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was based on predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data were collected on overall study characteristics and examination characteristics of the selected studies. Methodological quality of the selected studies was evaluated. Original studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Thereafter, levels of evidence were obtained according to Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

As a result of the QUADAS assessment, a total of 37 articles were included in the protocol. Following a proper protocol, CBCT was regarded as a reliable tool for assessment and management of impacted canine and root fracture. It provided a better evaluation of normal and pathological condylar shape and volume. CBCT was a superior choice for pre-surgical diagnostic applications in cleft lip and/or palate over a medical computed tomography based on its lower radiation exposure, shorter investigation time, and low purchase costs.

CONCLUSIONS

CBCT is justified only in those cases where conventional radiography fails to provide a correct diagnosis of pathology. Therefore, it cannot be regarded as a standard method of diagnosis. CBCT imaging may also be justified when it positively affects treatment options or provides treatment optimization.

REGISTRATION

None.

CONFLICT OF INTEREST

None to declare.

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.

Endodontic microsurgery. Part one: diagnosis, patient selection and prognoses

Historically, surgical endodontics has been viewed as a treatment of last resort, mainly due to poor outcomes as a result of limitations in materials and techniques. Contemporary techniques, modern materials and better visualisation have all led to an improvement in success rates, making endodontic microsurgery a valuable treatment option to certain patients. Such advances, however, are no substitute for skill in endodontic diagnosis and treatment planning, which can often prove challenging. A variety of tools are available to test for fractures and assess both periodontal and pulpal health. More advanced techniques such as cone beam computed tomography are often invaluable in pre-surgical assessment and diagnosis. Once an accurate diagnosis has been established, a favourable prognosis is explicitly linked to careful patient selection. Orthograde treatment, or retreatment, remains the gold standard for the majority of endodontic problems. However, there are a number of indications for surgery where orthograde treatment is either impossible, or less likely to be successful. It is paramount for any clinician undertaking endodontic surgery to have a detailed understanding of the local and systemic factors associated with successful treatment. Whilst there are few absolute medical contraindications, there are a number of conditions which may influence patient management and make treatment more challenging.

Cone-beam computed tomography imaging of dentoalveolar and mandibular fractures

Three-dimensional imaging methods have an important role in the diagnosis of dentomaxillofacial fractures that can not be seen on the plain films. Cone-beam computed tomography (CBCT) is one of the three-dimensional imaging methods and has facilitated dental professionals' access to cross-sectional imaging. CBCT units allow different technical parameters and the data acquired by CBCT, can be reformatted. Osseous structures are correctly examined with this technique but the technique is not useful for the examination of soft tissues. Therefore, the purpose of its use should be based on the expected diagnostic gain. The aim of this review is to present the use of CBCT with different multi-planar reformatted sections and three-dimensional reconstructions of dentoalveolar and mandibular fractures.

Accuracy of Periapical Radiography and CBCT in Endodontic Evaluation

Introduction

A radiological evaluation is essential in endodontics, for diagnostic purposes, planning and execution of the treatment, and evaluation of the success of therapy. The periapical radiography is nowadays the main radiographic investigations used but presents some limits as 3D anatomic alteration, geometric compression, and possible anatomical structures overlapping that can obscure the area of interest. CBCT (cone beam computed tomography) in endodontics allows a detailed assessment of the teeth and surrounding alveolar anatomy for endodontic diagnosis, treatment planning, and follow-up.

Objective

The purpose of this study was to evaluate the accuracy of CBCT in comparison with conventional intraoral radiographs used in endodontic procedures.

Materials and Methods

Statistical analysis was performed on 101 patients with previous endodontic treatments with the relative radiographic documentation (preoperative, postoperative, and follow-up intraoral X-ray) that had underwent at CBCT screening for surgical reasons. The CBCT scans were evaluated independently by two operators and compared with the corresponding periapical images.

Results

Our analysis shows that the two radiological investigations statistically agree in 100% of cases in the group of patients without any endodontic sign. In the group of patients with an endodontic pathology, detected with CBCT, endodontic under extended treatments (30.6%), MB2 canals in nontreated maxillary molars (20.7%), second canals in nontreated mandibular incisors (9%), root fractures (2.7%), and root resorption (2.7%) were not always visible in intraoral X-ray. Otherwise, positivity in the intraoral X-ray was always confirmed in CBCT. A radiolucent area was detected in CBCT exam in 46%, while the intraoral X-ray exam was positive only in 18%.

Conclusions

Our study shows that some important radiological signs acquired using CBCT are not always visible in periapical X-ray. Furthermore, CBCT is considered as a II level exam and could be used to solve diagnostic questions, essential to a proper management of the endodontic problems.

Automatic quantification framework to detect cracks in teeth

Studies show that cracked teeth are the third most common cause for tooth loss in industrialized countries. If detected early and accurately, patients can retain their teeth for a longer time. Most cracks are not detected early because of the discontinuous symptoms and lack of good diagnostic tools. Currently used imaging modalities like Cone Beam Computed Tomography (CBCT) and intraoral radiography often have low sensitivity and do not show cracks clearly. This paper introduces a novel method that can detect, quantify, and localize cracks automatically in high resolution CBCT (hr-CBCT) scans of teeth using steerable wavelets and learning methods. These initial results were created using hr-CBCT scans of a set of healthy teeth and of teeth with simulated longitudinal cracks. The cracks were simulated using multiple orientations. The crack detection was trained on the most significant wavelet coefficients at each scale using a bagged classifier of Support Vector Machines. Our results show high discriminative specificity and sensitivity of this method. The framework aims to be automatic, reproducible, and open-source. Future work will focus on the clinical validation of the proposed techniques on different types of cracks ex-vivo. We believe that this work will ultimately lead to improved tracking and detection of cracks allowing for longer lasting healthy teeth.

The Effects of Imaging Enhancement Tools in the Detection of Horizontal Root Fractures

INTRODUCTION

Detection of root fracture is challenging both clinically and radiographically. Root fractures occur in different planes with unpredictable presentations.

AIM

The aim of the study was to evaluate the diagnostic accuracy of selected digital image enhancement tools in the detection of horizontal Root Fracture (RF).

MATERIALS AND METHODS

Fifty three roots, of single and multi-rooted teeth, in eight dentate human cadaver mandibles were selected for this study. Following minimally traumatic extraction of the teeth, horizontal fractures were induced in 23 roots and remounted in the empty sockets of their respective human dry mandibles. The remaining teeth with no fractures were used as the control group. Twenty two periapical radiographs were obtained by using the paralleling technique and using Complementary Metal Oxide Semiconductor (CMOS). Image J software was used to enhance the original images with the Inversion (IN), Histogram-Equalization (EQ) and Polynomial (Poly) tools. A total of 88 periapical images (original and three enhanced images) were reviewed independently by three Oral and Maxillofacial Radiologists and two Endodontists. Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the accuracy of fracture detection and the kappa statistic was used to assess agreement among reviewers.

RESULTS

The diagnostic accuracy for one of the observers was significantly different in detection of RF with only EQ enhancement tool. Sensitivity and specificity were not significantly different. Interobserver agreement showed no significant difference between imaging methods. Intra-observer agreement was high to moderate.

CONCLUSION

There was no significant difference between the different imaging modalities. No statistical difference for the agreement was found among or between the endodontists and radiologists in this study.

Vertical root fracture: Biological effects and accuracy of diagnostic imaging methods

This review assessed the most up-to-date literature on the accuracy of detecting vertical root fractures (VRFs] using the currently available diagnostic imaging methods. In addition, an overview of the biological and clinical aspects of VRFs will also be discussed. A systematic review of the literature was initiated in December of 2015 and then updated in May of 2016. The electronic databases searched included PubMed, Emabse, Ovid, and Google Scholar. An assessment of the methodological quality was performed using a modified version of the quality assessment of diagnostic accuracy studies tool. Twenty-two studies were included in this systematic review after applying specific inclusion and exclusion criteria. Of those, 12 favored using cone beam computed tomography (CBCT) for detecting VRF as compared to periapical radiographs, whereas 5 reported no differences between the two methods. The remaining 5 studies confirmed the advantages associated with using CBCT when diagnosing VRF and described the parameters and limitations associated with this method, but they were not comparative studies. In conclusion, overwhelming evidence suggests that the use of CBCT is a preferred method for detecting VRFs. Nevertheless, additional well controlled and high quality studies are needed to produce solid evidence and guidelines to support the routine use of CBCT in the diagnosis of VRFs as a standard of care.

Cone beam computed tomography aided diagnosis and treatment of endodontic cases: Critical analysis

Although intraoral radiographs still remain the imaging method of choice for the evaluation of endodontic patients, in recent years, the utilization of cone beam computed tomography (CBCT) in endodontics showed a significant jump. This case series presentation shows the importance of CBCT aided diagnosis and treatment of complex endodontic cases such as; root resorption, missed extra canal, fusion, oblique root fracture, non-diagnosed periapical pathology and horizontal root fracture. CBCT may be a useful diagnostic method in several endodontic cases where intraoral radiography and clinical examination alone are unable to provide sufficient information.

Effect of Amperage and Field of View on Detection of Vertical Root Fracture in Teeth with Intracanal Posts

INTRODUCTION

This study sought to assess the effects of amperage (mA) and field of view (FOV) on intracanal metal post artifacts and the diagnostic parameters for detection of vertical root fracture (VRF) in teeth with intracanal posts.

METHODS AND MATERIALS

In this diagnostic study, 80 human single-canal teeth were evaluated by cone-beam computed tomography (CBCT). Nickel chrome cast posts were placed into root canals after root canal therapy and canal preparation. In the test group, fracture was induced by an instron machine while no fracture was induced in the control group. Deterministic and probabilistic sensitivity and specificity values at different exposure settings were statistically analyzed using the one-way ANOVA and pairwise comparisons were performed by Tukey's test.

RESULTS

Significant differences were found between the two groups in terms of deterministic (P<0.0001) and probabilistic (P<0.013) sensitivity and deterministic (P<0.037) and probabilistic (P<0.0001) specificity at different FOV and mA combinations.

CONCLUSION

A smaller FOV and lower mA should be preferably used for detection of VRFs in teeth with intracanal posts.

Accuracy of Digital Subtraction Radiography in the Detection of Vertical Root Fractures

INTRODUCTION

The objective of this study was to evaluate the accuracy of digital subtraction radiography in the diagnosis of vertical root fractures (VRFs).

METHODS

Twenty decoronated uniradicular human teeth were placed in the alveoli of a dry mandible and radiographed twice, first without (unfilled roots) and then with (filled roots) a gutta-percha cone placed into the root canal. Roots were then removed from the dry mandible, and vertical fractures were created with the aid of a universal testing machine. The fractured roots were repositioned in the mandibular alveoli and again radiographed twice. Radiographic images were subtracted by using the Regeemy software in 3 test situations: group 1, initial radiographic images of unfilled roots and images of fractured or non-fractured unfilled roots; group 2, initial radiographic images of unfilled roots and images of fractured or non-fractured filled roots; and group 3, initial radiographic images of filled roots and images of fractured or non-fractured filled roots. Three examiners evaluated all the original digital radiographs, as well as the subtracted images, for the presence or absence of VRFs. Numerical data were subject to statistical analysis with the use of receiver operator characteristic (ROC) curves.

RESULTS

The areas under the ROC curve for groups 1, 2, and 3 were 0.86, 0.73, and 0.66, respectively. For the original digital radiographs, areas under the ROC curve were 0.80 (without gutta-percha) and 0.73 (with gutta-percha). No statistically significant differences were found between subtracted and original images.

CONCLUSIONS

Digital subtraction radiography could be considered as an alternative tool for the investigation of VRFs because of its comparable diagnostic accuracy to existing methods.

Human identification study by means of frontal sinus imaginological aspects

The objective of this study was to evaluate the applicability of human identification parameters, established by Tatlisumak et al. (2007), by means of cone-beam computed tomography and extraoral radiographs of the frontal sinus region. From a total of 58 dry skulls, 26 were selected. Posteroanterior, profile cephalometric radiographs and cone-beam computed tomography images were acquired, adopting a specific method for reproducibility purposes. The images were evaluated by two examiners, previously calibrated, in a darkened environment and at two distinct sessions, with a minimum of 15 days between them. The characteristics of the frontal sinus were analyzed using the Cohen's kappa test, for categorical variables, and Lin's concordance correlation coefficient (CCC) for continuous variables. Acceptable values of inter method variability for the categorical variables were found, while same cannot be told for continuous variables. The parameters evaluated for the frontal sinus on extraoral radiographs and cone-beam computed tomographs were mostly concordant, with the exception of three. Categorical and discrete variables showed an intra- and interexaminer concordance ranging from good to perfect, and the quantitative continuous variables showed concordance ranging from moderate to excellent. The parameters examined are applicable and reproducible using multiplanar reconstructions of cone-beam computed tomography and extraoral radiographs of the frontal sinus.

Detection of artificially induced vertical root fractures of different widths by cone beam computed tomography in vitro and in vivo

AIMS

To compare the diagnostic accuracy of cone beam computed tomography (CBCT) for the detection of artificially induced vertical root fractures (VRFs) of different widths in vitro and in vivo.

METHODOLOGY

Vertical root fractures were induced in 25 extracted nonendodontically treated single-rooted human teeth (maxillary first premolars, maxillary canines and mandibular incisors). Twenty teeth without VRFs served as a control group. CBCT scanning (3D Accuitomo 170) was performed in vitro and in vivo. For the in vivo scanning, teeth were autoclaved, embedded into bite plates, placed in sterile plastic bags and then inserted into the mouths of volunteers. Teeth with VRFs were sectioned into axial slices and examined using a stereomicroscope to measure the widths of the VRFs. Five observers assessed the presence of VRFs using axial CBCT. Values for sensitivity, specificity, accuracy and interexaminer agreement were calculated.

RESULTS

The accuracy, specificity and sensitivity of CBCT were significantly higher in vitro than in vivo for VRFs with widths 50-150 μm (P < 0.05). The sensitivity and accuracy of CBCT were significantly higher for the detection of VRFs with widths greater than 150 μm in vivo and in vitro (P < 0.05). The accuracy of CBCT in vivo was 0.29 and 0.8 for fracture widths ranging from 50 to 150 μm and wider than 150 μm, respectively. No significant differences in CBCT specificity were found between VRF widths both in vitro and in vivo. The interexaminer reliability of the raters revealed a kappa value of 0.72, demonstrating substantial agreement.

CONCLUSION

The detectability of VRFs by CBCT in vitro and in vivo was dependent upon fracture width. The accuracy of CBCT in detecting VRFs of 50-300 μm width in vivo was significantly lower compared to the in vitro accuracy.

Influence of CBCT enhancement filters on diagnosis of vertical root fractures: a simulation study in endodontically treated teeth with and without intracanal posts

OBJECTIVES

To evaluate the influence of CBCT enhancement filters on the diagnosis of vertical root fractures (VRFs) in teeth with and without metal posts.

METHODS

The crowns of 40 uniradicular human teeth were removed and all roots were prepared. 20 teeth were randomly selected, and VRFs were induced using a universal testing machine. The i-CAT (Imaging Sciences International, Hatfield, PA) CBCT was used to scan teeth with and without intracanal metal posts using the following parameters: 0.2 voxel size, 8 × 8-cm scan size and acquisition time of 26.9 s. Images were evaluated by three observers with and without the use of the following filters: S9, smooth, smooth 3 × 3, sharpen, sharpen-mild and sharpen 3 × 3.

RESULTS

Intra- and interobserver agreement ranged from poor to moderate. Images with and without CBCT filters did not show significant differences regarding the area under the receiver operating characteristic curve, as well as sensitivity (p > 0.05). As for accuracy, the sharpen-mild filter was superior to the sharpen (p = 0.03), but these filters did not differ from all others. For specificity, S9, smooth and original images were superior to sharpen (p < 0.01). Results for teeth without posts differed from those for teeth with metal posts in all cases (p < 0.05).

CONCLUSIONS

The use of enhancement filters in CBCT images has no influence on the diagnosis of VRFs in teeth with metal posts, and their use is not justified.

Influence of the artefact reduction algorithm of Picasso Trio CBCT system on the diagnosis of vertical root fractures in teeth with metal posts

OBJECTIVES

To assess the influence of the artefact reduction algorithm (AR) available on the Picasso Trio 3D(®) imaging system (Vatech, Hwaseong, Republic of Korea) on image quality [greyscale values, contrast-to-noise ratio (CNR) and artefact formation] and diagnosis of vertical root fractures (VRFs) in the teeth with intracanal metal posts.

METHODS

30 uniradicular teeth had their crowns removed and their roots endodontically treated to receive intracanal metal posts. In 20 teeth, both complete (n = 10) and incomplete (n = 10) VRFs were created. Each tooth was scanned twice, with and without AR activation. The mean and variation of greyscale values, as well as CNR, were calculated for all images. Subsequently, an evaluator compared the amount of artefact (cupping, white streaks and dark bands) in all images. Five evaluators rated for VRF presence using a five-point scale.

RESULTS

Mean greyscale values and CNR were significantly decreased in images acquired with the AR. The usage of the algorithm promoted an overall reduction of image artefacts. Regarding the diagnosis of complete and incomplete VRFs, the use of the AR had an overall negative impact on specificity and accuracy.

CONCLUSIONS

While indeed reducing artefact formation, the use of the AR, instead of improving the impact on the diagnosis of VRFs in teeth with intracanal metal posts, had a negative impact on the diagnosis.

The importance of cone-beam computed tomography in the management of endodontic problems: a review of the literature

INTRODUCTION

To obtain essential information in clinical endodontics, cone-beam computed tomographic (CBCT) imaging can be used in all phases of treatment including diagnosis, treatment planning, during the treatment phase, and through post-treatment assessment and follow-up. The purpose of this article was to review the use of CBCT imaging in the diagnosis, treatment planning, and assessing the outcome of endodontic complications.

METHODS

Literature was selected through a search of PubMed electronic databases for the following keywords: tooth root injuries, tooth root radiography, tooth root perforation, tomography, cone-beam computed tomography, endodontic complications, tooth root internal/external resorption, root fractures, and broken instruments. The research was restricted to articles published in English. One hundred twelve articles met the inclusion criteria and were included in this review.

RESULTS

Currently, intraoral radiography is the imaging technique of choice for the management of endodontic disease, but CBCT imaging appears to have a superior validity and reliability in the management of endodontic diagnosis and complications.

CONCLUSIONS

Endodontic cases should be judged individually, and CBCT imaging should be considered in situations in which information from conventional imaging systems may not yield an adequate amount of information to allow the appropriate management of endodontic problems. CBCT imaging has the potential to become the first choice for endodontic treatment planning and outcome assessment, especially when new scanners with lower radiation doses will be available.

The 'Sharpen' filter improves the radiographic detection of vertical root fractures

AIM

To compare the diagnostic accuracy of digital enhancement filters in the diagnosis of vertical root fractures.

METHODOLOGY

The sample consisted of 40 single-rooted teeth randomly divided into two groups: experimental and control. Vertical root fractures were induced in the experimental group using a universal testing machine. All teeth were individually radiographed with three different horizontal angles using the Digora Optime(®) digital system. Three observers separately examined the original and filtered images (3D Emboss, Negative, Sharpen and Shadow). The area under Receiver Operating Characteristic curve values (Az) for each protocol were compared by one-way anova with post hoc Bonferroni test. The significance level was set at 5%.

RESULTS

The highest Az value was obtained using the Sharpen filter, with significant differences from the original and other filtered images (P < 0.05). The 3D Emboss filter had the lowest Az value, which was significantly different from the other filtered images (P < 0.05).

CONCLUSION

When using the Digora Optime(®) system, the 'Sharpen' filter is recommended to improve the radiographic detection of vertical root fractures.

Accuracy of digital radiography and cone beam computed tomography on periapical radiolucency detection in endodontically treated teeth

Objectives

The aim of the present study was to compare the accuracy of intraoral digital periapical radiography and cone beam computed tomography in the detection of periapical radiolucencies in endodontically treated teeth.

Material and Methods

Radiographic images (cone beam computed tomography [CBCT] scans and digital periapical radiography [PR] images) from 60 patients, achieved from September 2008 to July 2013, were retrieved from databases of the Department of Oral Diseases, Lithuanian University of Health Sciences. Twenty patients met inclusion criteria and were selected for further evaluation.

Results

In 20 patients (42.4 [SD 12.1] years, 65% men and 35% women) a total of 35 endodontically treated teeth (1.75 [SD 0.91]; 27 in maxilla and 8 in mandible) were evaluated. Overall, it was observed a statistical significant difference between the number of periapical lesions observed in the CBCT (n = 42) and radiographic (n = 24) examinations (P < 0.05). In molar teeth, CBCT identify a significantly higher amount of periapical lesions than with the radiographic method (P < 0.05). There were significant differences between CBCT and PR in the mean number of lesions identified per tooth (1.2 vs 0.66, P = 0.03), number of teeth with lesions (0.71 vs 0.46, P = 0.03) and number of lesions identified per canal (0.57 vs 0.33, P = 0.005). Considering CBCT as “gold standard” in lesion detection with the sensitivity, specificity and accuracy considering as score 1, then the same parameters of PR were 0.57, 1 and 0.76 respectively.

Conclusions

Within the limitations of the present study, it can be concluded that cone beam computed tomography scans were more accurate compared to digital periapical radiographs for detecting periapical radiolucencies in endodontically treated teeth. The difference was more pronounced in molar teeth.

Vertical root fractures and their management

Vertical root fractures associated with endodontically treated teeth and less commonly in vital teeth represent one of the most difficult clinical problems to diagnose and treat. In as much as there are no specific symptoms, diagnosis can be difficult. Clinical detection of this condition by endodontists is becoming more frequent, where as it is rather underestimated by the general practitioners. Since, vertical root fractures almost exclusively involve endodontically treated teeth; it often becomes difficult to differentiate a tooth with this condition from an endodontically failed one or one with concomitant periodontal involvement. Also, a tooth diagnosed for vertical root fracture is usually extracted, though attempts to reunite fractured root have been done in various studies with varying success rates. Early detection of a fractured root and extraction of the tooth maintain the integrity of alveolar bone for placement of an implant. Cone beam computed tomography has been shown to be very accurate in this regard. This article focuses on the diagnostic and treatment strategies, and discusses about predisposing factors which can be useful in the prevention of vertical root fractures.

A Diagnosis of Maxillary Sinus Fracture with Cone-Beam CT: Case Report and Literature Review

The purpose of this article is to present the case of maxillofacial trauma patient with maxillary sinus fracture diagnosed with cone-beam computed tomography (CBCT) and to explore the applications of this technique in evaluating the maxillofacial region. A 23-year-old male patient attempted to our clinic who had an injury at midface with complaints of swelling, numbness. The patient was examined before in emergency center but any diagnosis was made about the maxillofacial trauma. The patient re-examined clinically and radiographically. A fracture on the frontal wall of maxillary sinus is determined with the aid of CBCT. The patient consulted with the department of maxillofacial surgery and it is decided that any surgical treatment was not necessary. The emerging technique CBCT would not be the primary choice of imaging maxillofacial trauma. Nevertheless, when advantages considered this imaging procedure could be the modality of choice according to the case.

The influence of metallic posts in the detection of vertical root fractures using different imaging examinations

OBJECTIVES

To assess the influence of metallic posts in the detection of simulated vertical root fractures (VRFs) using the following imaging examinations: 2 cone beam CT (CBCT) systems [CBCT1: NewTom(®) 3G (QR Srl, Verona, Italy) and CBCT2: i-CAT Next Generation(®) (Imaging Sciences International, Hatfield, PA)] and film and digital radiographs. Additionally, the influence of the orientation of the fracture line in the detection of VRFs was evaluated.

METHODS

100, human, single-rooted endodontically treated premolars were divided into 5 groups (Group 1: with posts and buccolingual VRFs, Group 2: with posts and mesiodistal VRFs, Group 3: without posts and with buccolingual VRFs, Group 4: without posts and with mesiodistal VRFs, and Group 5: with posts and without VRFs). The premolars were placed in human mandibles and imaged using the four examination modalities. The sensitivity and the specificity of each examination in the experimental groups were calculated. The data were analysed using Student's t-test.

RESULTS

The presence of metallic posts reduced the sensitivity of the CBCT1 system (p = 0.0244). Digital radiographs and the CBCT1 and CBCT2 systems had a higher sensitivity in detecting buccolingual fractures in teeth with posts, whereas film and digital radiographs had a higher sensitivity in detecting buccolingual fractures in teeth without posts (p < 0.05). The CBCT1 examination demonstrated the lowest specificity (p < 0.05).

CONCLUSIONS

The presence of metallic posts did not influence the sensitivity of most of the examinations, excluding the CBCT1 system. The fracture line orientation may influence VRF detection.

Comparative diagnostic yield of cone beam CT reconstruction using various software programs on the detection of vertical root fractures

OBJECTIVES

To evaluate the effect on diagnostic yield in the detection of experimentally induced vertical root fractures on cone beam CT images using four dental software program.

METHODS

190 single-rooted extracted human teeth were divided into three groups according to the pulp canal status: unrestored (UR), filled with gutta-percha (GP) and restored with a metallic custom post (Post). One-half of the sample of each group was artificially fractured and the segments repositioned. All teeth were scanned on a cone beam CT device at 0.2 mm nominal voxel resolution (i-CAT Platinum; Imaging Sciences International, Hatfield, PA). The data were exported as digital imaging and communications in medicine files and imported into Dolphin Imaging & Management Solutions, v. 11.5 (Patterson Dental Supply Inc., St Paul, MN), InVivoDental, v. 5.0 (Anatomage Inc., San Jose, CA) and Kodak Dental Imaging Software 3D module, v. 2.1.11 (Carestream Health Inc., Rochester, NY) software. Cross-sectional images in the acquisition (using Xoran CAT™, v. 3.0.34 software; Xoran Technologies, Ann Arbor, MI) and additional software were presented to three calibrated oral radiologists who rated the presence or absence of root fracture on a five-point scale. Receiver operating characteristic analysis was performed, and treatment comparisons compared by analysis of variance and pairwise comparisons were performed using Tukey's test at an a priori value of α < 0.05%.

RESULTS

All dental software performed equally at detecting fractures. Fractures were significantly more difficult to detect when posts were present.

CONCLUSIONS

The diagnosis of root fracture is software-independent. The presence of an intracanal metallic post significantly decreases the detection of artificially created root fractures.

Application of cone beam computed tomography in oral and maxillofacial surgery

In the past decade, the utility of cone beam computed tomography (CBCT) images in oral and maxillofacial surgery has seen continuous increase. However, CBCT images are not always able to replace other imaging modalities. Based on the current published knowledge, this paper discusses advantages and limitations of CBCT images in the diagnosis and surgical planning of dentoalveolar procedures, odontogenic cysts, benign and malignant tumours, inflammatory changes, orthognathic surgery, maxillofacial trauma, sinus disorders, and systemic and osseous conditions that manifest in the maxillofacial area. This paper also suggests alternative imaging modalities when CBCT images are not adequate for surgical planning.