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Basic Research—Technology

The Use of Cone-beam Computed Tomography and Digital

Periapical Radiographs to Diagnose Root Perforations
Hagay Shemesh, PhD, Roberto C. Cristescu, DDS, Paul R. Wesselink, PhD, and Min-Kai Wu, PhD

Introduction: The aim of this study was to compare the
sensitivity and specificity of cone-beam computed
tomography (CBCT) scans and digital periapical radio-
A perforation is a communication between the root canal system and the external root
surface (1). It is an undesirable incident that can occur at any stage of endodontic
treatment and is usually iatrogenically induced. According to the Washington study, root
graphs (PR) in detecting strip and root perforations after perforations result in endodontic failures accounting for about 10% of all failed cases
root canal treatment in mandibular molars. Methods: (2). In phase 3 and 4 of the Toronto study (3), the observed healed rate in teeth with
Forty-five curved mesial roots were endodontically a perforation was 31% lower than in teeth without perforation.
prepared. Fifteen roots were perforated in the mesiolin- A definite diagnosis of perforations in endodontically treated teeth may sometimes
gual canal by inserting a rotary file through the canal be challenging because of the absence of pathognomonic clinical symptoms and the
curvature penetrating the root surface (‘‘root perfora- limited capacity of periapical radiographs (PRs) to image these perforations (4).
tion’’), and 15 roots were perforated with a drill in the However, timely detection of perforations will aid in selecting the proper therapy, mini-
axial aspect of the canal (‘‘strip perforation’’). Fifteen mizing bone loss, predicting outcome, and analyzing failures (5). Perforations are
roots were not perforated. All mesial roots were filled usually classified by size, location, type, length of time before repair, and degree of
with gutta-percha and AH26. Teeth were then placed bone destructions (6).
in human mandibles. PRs from two angulations and Various instruments and techniques were suggested for the clinical diagnosis of
CBCT scans were evaluated by two observers. The sensi- root perforations. These include electronic apex locator (4, 7), operative
tivity and specificity of both methods to diagnose perfo- microscope (8), endoscope (9), and an optical coherence tomography scan (10).
rations were calculated. Results: The sensitivity and However, none of these could diagnose perforations in already filled roots because
specificity of CBCT scans in the detection of strip perfo- they are based on visualization of the empty root canal or penetration into it.
rations were 0.50 and 0.97, respectively, and with two- Cone-beam computed tomography (CBCT) scans were recently shown to be a valu-
angled PRs they were 0.13 and 0.97. For the detection able diagnostic tool in the following stages of the endodontic treatment: characterizing
of root perforations, the sensitivity and specificity of the periapical lesion and its healing process, (11) diagnosing vertical root fractures
CBCT scans were 0.86 and 0.70, respectively, and for (12), assessing the anatomy of the internal and external aspects of the tooth (13,
PRs they were 0.66 and 0.90. The difference between 14), and localizing root resorption defects (15). The purpose of this study was to eval-
PRs and CBCT scans in detecting strip perforations was uate the accuracy of a clinical dental CBCT system in comparison with PRs in detecting
significant (chi-square test, P < .05). Conclusions: The root and strip perforations in root-filled teeth.
risk to misdiagnose strip perforations was high with
both methods, but CBCT scans showed a significant Materials and Methods
higher sensitivity than PR. There was no significant Forty-five extracted intact human mandibular molar teeth were selected and stored
difference between the methods for the detection of in purified filtered water. Radiographs were taken, and the mesial root curvature was
root perforations. (J Endod 2011;37:513–516) measured (16). Three groups (n = 15) were formed so that the average angle of the
mesial roots was 50 to 52 .
Key Words Endodontic opening was performed, and canal patency was established with size
Cone-beam computed tomography, diagnosis, periapi- 20 K-Flexofile (Dentsply Maillefer, Ballaigues, Switzerland). Thereafter, the two mesial
cal radiographs, root perforation canals were prepared with SystemGT rotary instruments (Dentsply Maillefer) at 300
rpm using a torque-control motor (ATR Technika, Pistoia, Italy). The last file used
has a taper of 0.06 and a diameter of 35. Each canal was repeatedly irrigated with
a freshly prepared 2% solution of sodium hypochlorite (NaOCl) using a syringe and
From the Department of Endodontology, Academic Centre a 27-G needle. Twelve milliliters of NaOCl solution was used for each root. After comple-
for Dentistry Amsterdam, University of Amsterdam and Free
University Amsterdam, Amsterdam, The Netherlands. tion of instrumentation, passive ultrasonic irrigation was performed with an Irrisafe 20/
Address requests for reprints to Dr Hagay Shemesh, ACTA, 21 file (Satelec, Merinac Cedex, France) in order to efficiently clean the canals and re-
Department of Endodontology, Room 2N37, Gustav Mahlerlaan move remaining debris (17). After completion of the procedure, canals were rinsed
3004 1081 LA, Amsterdam, The Netherlands. E-mail address: with 2 mL distilled water. All roots were kept moist in water throughout the experimental
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2010.12.003 Root Perforation
One group of teeth (n = 15) was not perforated. In the two remaining groups, 15
teeth in each, the mesiolingual canal was perforated. In the ‘‘root perforation’’ group,
the 30.04 SystemGT file (Dentsply Maillefer) was deliberately used to perforate the root
beyond the curvature until the file was visible on the outside root surface in the apical

JOE — Volume 37, Number 4, April 2011 Diagnosis of Root Perforations with CBCT 513
Basic Research—Technology

Figure 1. Root and strip perforation as seen through PRs and CBCT scans.

third of the root. In the ‘‘strip perforation’’ group, a Gates Glidden drill Data and Statistical Analysis
no. 3 (Dentsply Maillefer) was rotated in an axial direction from within A perforation was diagnosed when a discontinuity in the tooth
the canal penetrating through the root at 1 to 3 mm below the furcation. structure at the periphery, either externally (root perforation) or
Both perforations were verified by inserting a size 20 K-Flexofile (Dents- around the furcation (strip perforation), was seen, either filled with
ply Maillefer) into the defect without any resistance. a filling material (gutta-percha or cement or both) or empty (Fig. 1).
Two observers were calibrated and examined the images separately.
They were instructed to look at perforations and grade their observa-
tions as ‘‘perforation,’’ ‘‘no perforation,’’ or ‘‘questionable.’’ CBCT
Canal Filling images were reviewed in the three reconstruction planes (axial,
All teeth were dried using three size 40 paper points (Dentsply De coronal, and sagittal). The overall agreement among observers was
Trey, Konstanz, Germany). AH 26 (Dentsply De Trey) was mixed ac- calculated by using Cohen’s kappa. When observations differed,
cording to the manufacturer’s instructions and introduced into the a consensus was reached after a discussion. A two-sided chi-square
canal on two occasions, 5 seconds each, using a lentulospiral (Dentsply test was used to analyze the sensitivity, specificity, and accuracy of
Maillefer) rotating at 400 rpm. Standardized size 35 gutta-percha cones both CBCT scans and PRs for the detection of perforations. The data
(Henry Schein, Mexico City, Mexico) with a 0.02 taper were coated with were analyzed on SPSS 16.0 software (SPSS Benelux, Gorinchem, The
sealer and placed into the root canal. Roots were filled with the lateral Netherlands), and the alpha value was set at 0.05.
compaction technique using a size C spreader (D1 diameter 0.3 mm,
0.04 taper; Dentsply Maillefer) and size 25 standardized gutta-percha
cones. All roots were kept in 100% humidity conditions at 37 C for 3 Results
weeks. The teeth were placed in premade sockets in dry human mandi- The sensitivity, specificity, and accuracy results for CBCT scans and
bles bilaterally in the posterior region. The mandibles were coated with two-angulation PRs in detecting root and strip perforations are reported
three layers of dental wax buccally and lingually to simulate soft tissue in Table 1. In total, 63% (19/30) of the perforations were detected
(11, 18). The total thickness of the wax layer was 1.5 mm. Impression by two-angulation PRs. Forty percent (12/30) of perforations were
material was used to fix the teeth in the mandible holes and to fill gaps
between the root surface and the socket.
TABLE 1. The Specificity, Sensitivity, and Accuracy of Diagnosing Perforations
with PRs and CBCT Scans
Scanner Parameter Root perforation Strip perforation
Radiographic Scan
Digital PRs were made with a fixed x-ray unit (Siemens Heliodent Sensitivity 0.86 0.50
MD, Erlangen, Germany) and new size 2 phosphor plate films (Digora, Specificity 0.70 0.96
Tuusula, Finland) following manufacturer’s recommendation. Two Accuracy 0.76 0.80
radiographs per tooth, mesio- and distoangulated, were taken. CBCT PR
scans were made with the Kodak 9000 3D System (120 KvP, 6 mA; Care- Sensitivity 0.66 0.13
Specificity 0.90 0.96
stream Health, Inc, Rochester, NY) with a field of view of 50  37 mm, Accuracy 0.82 0.69
a voxel size of 76  76  76 mm, and an exposure time of 10 seconds.

514 Shemesh et al. JOE — Volume 37, Number 4, April 2011

Basic Research—Technology
detected by the mesioangulated radiographs and 37% (11/30) by the
distoangulated radiographs. CBCT scans detected 87% (26/30) of
perforations. CBCT scans were overall significantly more accurate
than PRs in detecting perforations (P < .001). The difference between
CBCT scans and PRs in diagnosing strip perforations was significant
(P = .022), but for the diagnosis of root perforation it was not signif-
icant (P = .2). The overall agreement among observers was substantial
for both PRs (k = 0.8) and CBCT scans (k = 0.7).

This study investigated the feasibility of CBCT scans and PRs in de-
tecting perforations in endodontically treated teeth. The inaccuracy of
PRs in detecting perforations was previously discussed (19), but clin-
ical practice still relies on PRs for assessing the progression and
outcome of the treatment.
The results of the current experiment show that the ability to diag-
nose strip perforations with PRs is very limited, and even CBCT scans
could not detect these perforations reliably (sensitivity 0.5). Very little
is reported in the literature on strip perforations; however, it is generally
thought that a perforation in the cervical third of the root or in the floor
of the pulp chamber has a poorer prognosis than one at the apical or
middle third of the root (20). Thus, the inability of both imaging tech-
niques to detect these perforations is a significant drawback. The
inability of PRs to detect these perforations may lie on the location of
the perforation, which could be masked by the concavity of the root
(Fig. 2).
The limited ability of CBCT scans to image strip perforations could
partly be explained by the absence of filling material penetrating inside
the perforation. The filling method used in the current study was lateral
compaction of gutta-percha and AH26 sealer. Carvalho-Sousa et al (21)
concluded that lateral compaction is less effective in sealing lateral
canals than warm or soft gutta-percha methods. It could be that filling
the canals with these methods would lead to better detection of the Figure 2. (A) The direction of the radiation beam will result in a projection
that masks the perforation site by the dentin bulk of the concavity. (B) Strip
perforation site. perforation is difficult to diagnose with PRs because of the concavity of the
The presence of a root canal filling reduces the specificity of CBCT root.
scans in diagnosing vertical root fractures (12). Radiopaque substances
such as gutta-percha cones and AH26 create streak artifacts on CBCT may be different because these perforations involve a relatively large
slices that can mimic fracture lines (22, 23). The same artifact can surface of very thin dentin in the inner aspect of a root curvature. These
be confused for perforation. clinical situations are difficult to mimic and standardize in vitro.
Because PRs are two-dimensional, changing the horizontal or A major drawback with CBCT scans is the high radiation dose and
vertical angulations of the radiation source could be helpful in deter- financial costs that are higher than conventional radiographs. By reduc-
mining the existence of additional roots, the location of pathosis, and tion of the scanned volume, the radiation dose will decrease. In this
anatomic structures. Additionally, a phosphor plates was used in the study, a relatively small scanned volume was observed; 12 to 24 axial
present study. Other digital detectors such as solid-state charge-coupled scans were taken with a slice thickness of 1.25 mm. It remains to be
device and complimentary metal-oxide semiconductor receptors seen if the costs of CBCT scans and the radiation dose will dramatically
should be checked for their ability to detect perforations as well. The decrease in the coming years.
results showed that single-angulated PRs detected only 40% of perfora-
tions. This percentage increased to 63% when two-angulated PRs were
used. The current results support clinical recommendation to take
radiographs from multiple angles in order to increase the chance to
diagnose perforations and their location (24). Under the condition of this in vitro study, the overall sensitivity of
Roots were perforated in the current experiment after the prepa- PRs and CBCT scans to diagnose strip perforations in root-filled teeth
ration procedure. Dentin debris could penetrate the perforation site was low although CBCT scans showed a significant higher accuracy
and prevent the filling material from entering it, resulting in lower visi- than PRs. There was no significant difference between the methods
bility of such a perforation in the scan. This could partly explain the low for the detection of root perforations.
sensitivity of both methods in the diagnosis of strip perforations.
Furthermore, strip perforations were artificially made in this study by
introducing a Gates Glidden bur to the mesiolingual canal in an exag- Acknowledgments
gerated axial direction. A perforation was verified by a communication The authors express their gratitude to R. Autar and Z.A. Ronkes
between the outside surface of the root and the root canal space. Agerbeek for their laboratory and clinical work on this experiment.
However, the perforation itself was usually small. The clinical situation The authors deny any conflicts of interest related to this study.

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