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Use of the metal artefact reduction tool in the identification of fractured

endodontic instruments in cone‐beam computed tomography

Article  in  International Endodontic Journal · October 2019

DOI: 10.1111/iej.13242

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 doi:10.1111/iej.13242

Use of the metal artefact reduction tool in the

identification of fractured endodontic instruments
in cone-beam computed tomography

E. D. Costa1 , D. M. Brasil1 , P. M. Queiroz1 , F. S. Verner2 , R. B. Junqueira3 &

D. Q. Freitas1
1
Division of Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas, Piracicaba;
2
Division of Oral Radiology, Department of Dentistry, Federal University of Juiz de Fora; and 3Division of Endodontic,
Department of Dentistry, Federal University of Juiz de Fora, Governador Valadares, Brazil

Abstract for the presence or absence of fractured files on a

Costa ED, Brasil DM, Queiroz PM, Verner FS,
Junqueira RB, Freitas DQ. Use of the metal artefact
reduction tool in the identification of fractured endodontic
instruments in cone-beam computed tomography.
International Endodontic Journal.
Aim To evaluate the influence of the metal artefact
reduction (MAR) tool in the diagnosis of fractured
instruments in root canals of extracted mandibular
molars, with or without root canal fillings.
Methodology The root canals of 31 mandibular
molars were divided into four groups: (i) the control
group, without root fillings; (ii) the fracture group,
without fillings and with fractured files; (iii) the fill
group, with root filling; and (iv) the fill/fracture
group, root filled and with fractured files. The follow-
ing instruments were used as fractured endodontic
instruments: stainless steel hand files, NiTi reciprocat-
ing files and NiTi rotary files. Each tooth was inserted
in a dry mandible to obtain cone-beam computed
tomography (CBCT) images using a CBCT OP300 3D
Maxio (Instrumentarium Dental, Tuusula, Finland)
and Picasso Trio (Vatech, Hwaseong, Republic of
Korea), with and without application of the MAR
tool. All images were evaluated by three radiologists
5-point scale. The diagnostic accuracy (area under
ROC curve) was calculated. Image noise was measured
in regions of trabecular and cortical bone and soft tis-
sue. The comparison between the ROC curve values
with the MAR tool enabled or disabled was performed
using a t-test. A t-test was also employed for compar-
ing image noise when the MAR tool was enabled and
disabled. The significance level was set at 5%.
Results The use of the MAR tool did not influence
the diagnostic accuracy for identifying fractured
endodontic instruments in root canals with and with-
out fillings in both CBCT systems (P > 0.05), nor did
it influence the image noise (P > 0.05).
Conclusions The MAR tool on these two devices
did not increase the detection of fractured endodontic
instruments and did not reduce image noise using
extracted mandibular molars. Therefore, the MAR tool
is not recommended for evaluation of fractured
endodontic instruments in teeth with and without
root fillings in mandibular molars.
Keywords: cone-beam computed tomography, en-
dodontics, instrumentation.
Received 26 May 2019; accepted 24 October 2019

Correspondence: Eliana Dantas Costa, Division of Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School,
University of Campinas, Av. Limeira 901, Arei~ao, Piracicaba, SP Zip Code 13414-018, Brazil (e-mail: edantasc@yahoo.com.br).

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 1
 MAR in the diagnosis of fractured instrument Costa et al.
Introduction
The fracture of instruments during root canal treat-
ment may compromise the preparation, disinfection
and filling of root canals (Rosen et al. 2014, Kocß et al.
2018).
The introduction of cone-beam computed tomogra-
phy (CBCT) in dentistry has allowed the three-dimen-
sional visualization of maxillofacial anatomy. In
endodontics, its use is only justified when diagnostic
information obtained through clinical examinations and
intraoral radiographs are not sufficient (ESE 2019).
According to the American Association of Endodon-
tists (AAE), the American Academy of Oral and Max-
illofacial Radiology (AAOMR) and the European
Society of Endodontology (ESE), CBCT is only recom-
mended in those cases in which lower dose two-di-
mensional radiography does not provide sufficient
information for confident diagnosis (AAE & AAOMR
Joint Position Statement 2015, ESE 2019). However,
when the region of interest contains metallic objects
(restorations, implants, endodontic instruments) or
root canal fillings, the high atomic number and den-
sity of these materials lead to the generation of arte-
facts, which are structures seen in the reconstructed
image, but which are not present in the real object
(Vasconcelos et al. 2017, Freitas et al. 2018). These
artefacts compromise the diagnostic accuracy of
CBCT, since they can lead to formation of white striae
and dark areas around anatomical structures of inter-
est, hindering or even rendering the diagnosis impos-
sible (Bechara et al. 2013, Queiroz et al. 2017, Freitas
et al. 2018, Kocß et al. 2018).
In order to improve image quality and to correct
defects due to artefacts, some CBCT systems provide
an metallic artefacts reduction tool (MAR), to reduce
the variability of grey values and increase the con-
trast-to-noise ratio in the image (Queiroz et al. 2017).
Thus, the aim of this study was to evaluate the
influence of the MAR tool in the identification of frac-
tured instruments in root canals of extracted
mandibular molars, with and without root fillings.
Material and methods
This study was approved by the local Research Ethics
Committee (CAAE: 84963418.6.0000.5418).
Sample selection
The sample consisted of 31 mandibular molars
extracted for therapeutic reasons, with 80 root canals.
2 International Endodontic Journal
Initially, a clinical/radiographic examination of the
teeth was performed to verify whether they met the
inclusion/exclusion criteria. The inclusion criteria
were straight or curved canals with <5° of curvature
(Rosen et al. 2014) with a closed apex. Teeth with
previous endodontic treatments, presence of root car-
ies lesions, as well as root resorption, visible root frac-
tures or fissures, supernumerary roots and pulp
calcifications were excluded. The root canals were
divided into four groups: (i) the control group, with
nonfilled canals; (ii) the fracture group, with nonfilled
canals and fractured files; (iii) the fill group, with
filled canals; and (iv) the fill/fracture group, with filled
canals and fractured files (Ramos Brito et al. 2017).
The distribution of such conditions was random
amongst the canals, and each tooth could have differ-
ent conditions in its mesiobuccal, mesiolingual and
distal canals.
Tooth preparation
Tooth preparation followed the methodology proposed
by Ramos Brito et al. (2017), with all stages being
performed by an endodontist. For this, root canal pre-
paration was performed with a single file (R25 instru-
ment, 25 mm; VDW, Munich, Germany), followed by
irrigation with 2.5% sodium hypochlorite, final irriga-
tion with EDTA and drying of the canals. For the root
filling, the McSpadden technique was used (Michelotto
et al. 2010), with a single gutta-percha cone (R25
cone, Reciproc; VDW) and zinc oxide-based cement
eugenol (Dentsply Sirona, Ballaigues, Switzerland).
The following instruments were used for teeth that
had fractured endodontic instruments: stainless steel
hand files (size 10 Flexofile; Dentsply Sirona), NiTi
reciprocating files (R25) and NiTi rotary files (F1 Pro-
Taper; Dentsply Sirona). First, to create a fracture
point, a groove was created on each instrument with
a diamond drill (3203; KG Sorensen, Cotia, SP, Brazil)
2 mm from the tip of the instrument. The instrument
was then inserted via the apical foramen and rotated,
thus causing an intentional fracture within the root
canals (D’Addazio et al. 2011).
Experimental setup
To simulate the periodontal space of a tooth inserted
within an alveolus, the roots were covered with
0.3 mm of utility wax (NewWax Technew, Rio de
Janeiro, RJ, Brazil) and placed in the same position
and in the same alveolus of a dry jaw, in the molar
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

region. For soft tissue simulation of the maxillofacial
region, the mandible was wrapped with 3 mm of
acrylic resin. To simulate the patient’s tissue responsi-
ble for X-rays interaction and secondary radiation
production, a tongue-shaped acrylic resin was also
used. The position of the mandible was standardized
in the centre of the FOV by means of the guiding
lights of the CBCT units, so that the alveolus with the
implanted tooth was in the same position for all
acquisitions. The images were acquired individually
for each tooth.
Image acquisition
The CBCT images were acquired using two systems,
using a FOV of 5 9 5 cm and a voxel of 0.2 mm,
with and without MAR tool activation. The following
systems were used: OP300 3D Maxio (Instrumentar-
ium Dental, Tuusula, Finland) with 10 mA and
90 kV; and Picasso Trio (Vatech, Hwaseong, Republic
of Korea) with 3.7 mA and 80 kV. After acquisition,
the CBCT images were exported in DICOM format
(Digital Imaging and Communications in Medicine),
totalling 124 CBCT volumes.
Image evaluation
Cone-beam computed tomography images were evalu-
ated using On Demand3D software (CyberMed, Seoul,
Republic of Korea) under low lighting conditions, inde-
pendently by three Oral Radiologists with experience in
evaluating CBCT images. The evaluators were previ-
ously calibrated in a training session. Each volume was
evaluated dynamically on all multiplanar reconstruc-
tions (Figs. 1 and 2). Brightness, contrast and zoom
tools were used according to the visual needs of each
evaluator. The roots were evaluated for the presence or
absence of fracture instruments in the root canals,
according to a five-point scale (1-definitely absent,
2-probably absent, 3-uncertain, 4-probably present,
5-definitely present; Ramos Brito et al. 2017). After
30 days, 25% of the sample was re-evaluated to assess
intra- and inter-evaluator reproducibility.
To quantify the effect of image noise, the ten teeth
containing the largest number of roots with root
canal filling and fractured instruments were selected.
Regions of interest (ROI) were set in three structures
trabecular bone, cortical bone and soft tissue near the
tooth using a ROI Manager tool (ImageJ software;
National Institutes of Health, Bethesda, MD, USA;
Fig. 1). Mean grey value and standard deviation were
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Costa et al. MAR in the diagnosis of fractured instrument
measured over five consecutive slices. The mean val-
ues of standard deviation (MVSD) were used to com-
pare image noise when using MAR tool enabled and
disabled in both CBCT systems. The analysis was per-
formed using 16-bit images for both devices.
Data analysis
The intra- and interobserver agreements were verified
using the Kappa test. The diagnostic values (area
under ROC curve, sensitivity and specificity) were cal-
culated. The area under the ROC curve (Az) is a
parameter that measures diagnosis performance and
tests whether the factors studied influence the diagno-
sis. The diagnostic values when using the MAR tool
enabled and disabled were compared using a t-test.
The t-test was also employed for comparing image
noise when using the MAR tool enabled and disabled.
The analyses were performed using MedCalc soft-
ware version 11.2.1.0 (MedCalc Software, Ostend,
Belgium). A significance level of 5% (a = 0.05) was
considered for all analyses.
Results
The intraobserver agreement was moderate to sub-
stantial (0.49–0.80), and interobserver agreement
(0.45–0.52) was moderate (Landis & Koch 1977).
The results revealed that the MAR tool did not
influence the identification of fractured endodontic
instruments in root canals in the absence and pres-
ence of root filling material in both systems
(P > 0.05; Table 1).
Moreover, image noise did not decrease when
applying the MAR tool for any region or device
(P > 0.05; Table 2).
Discussion
The metallic composition of endodontic instruments
generates image artefacts, which when associated
with the artefacts produced by root filling materials,
can make it difficult to identify fractured instruments
inside root canals. In this sense, as a proposal to
improve image quality, several CBCT systems provide
an MAR tool. Thus, the present study tested the
hypothesis that the MAR tool could improve the
detection of fractured endodontic instruments by
allowing the instrument to be observed in unfilled
canals or differentiating the instrument from root fill-
ing material in filled canals.
International Endodontic Journal 3
 MAR in the diagnosis of fractured instrument Costa et al.
Figure 1 Images of axial reconstructions using the metal artefact reduction tool disabled and enabled for OP300 (a, b) and
Picasso Trio (c, d) cone-beam computed tomography (CBCT) systems. Regions of interest set in trabecular bone, cortical bone
and soft tissue (a).
The results of the present study revealed that the
use of the MAR tool did not improve diagnostic accu-
racy in any of the simulated clinical conditions tested.
It can be hypothesized that the action of the MAR tool
was not effective in the present study, because only a
small number of artefacts were created due to the
small dimensions of the instrument (2 mm). In the
same way, the lack of an improvement in their detec-
tion in filled canals can be attributed to the composi-
tion of gutta-percha (mixture of zinc oxide and
isoprene rubber), which has a low atomic number
(Queiroz et al. 2018), and thus does not generate suffi-
cient artefacts to be significantly reduced by the MAR
tool (Freitas et al. 2018, Queiroz et al. 2018). There-
fore, it can be inferred that the detection of fractured
instruments in filled canals is difficult not because of
the direct effect of the artefacts, but because the gutta-
percha and endodontic instruments produce a similar
density on the final images that does not allow the
root filling and instrument to be differentiated.
Previous studies (Bechara et al. 2013, Bezerra et al.
2015) have verified that the use of the MAR tool has
a negative impact on the diagnosis of root fractures
4 International Endodontic Journal
in root filled canals. Likewise, Vasconcelos et al.
(2015) reported an increase in artefact generation
when evaluating the use of the MAR tool in filled
canals. On the other hand, in studies using metallic
materials such as implants (zirconia and titanium;
Vasconcelos et al. 2017, Freitas et al. 2018) and for
evaluation of proximal caries in the presence of
some materials with a high atomic number (Cebe
et al. 2017), the MAR tool was effective. Thus, it
can be inferred that the MAR tool has a greater
potential to correct artefacts generated by materials
with a high atomic number, as suggested by Queiroz
et al. (2018) when evaluating the impact of the
use of the MAR tool in the presence of various
dental materials, amongst them metallic alloys and
gutta-percha.
Although there are doubts about the effectiveness
of the MAR tool, it is suggested that this tool works
in the post-processing stage, correcting highly dense
or sparse regions in the image, that is, acting by
applying a threshold in relation to the grey value
average in the image and increasing the contrast-to-
noise ratio (Bechara et al. 2013, Queiroz et al. 2017,
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Costa et al. MAR in the diagnosis of fractured instrument

Figure 2 Sagittal multiplanar reconstructions showing a root with a fractured stainless steel hand file (left) and a root with a
fractured NiTi rotary file and root filling material (right), using the metal artefact reduction tool disabled and enabled for
OP300 (a, b) and Picasso Trio (c, d) cone-beam computed tomography (CBCT) systems.

Table 1 Mean and standard deviation (SD) values of area under ROC curve (Az), sensitivity and specificity of fractured
endodontic instruments identification when using MAR tool disabled and enabled, in the absence and presence of root filling
material

CBCT systems

OP300 Picasso Trio

Az Sensitivity Specificity Az Sensitivity Specificity

In the absence of a root filling

MAR disabled 0.87 (0.03) 0.69 (0.07) 0.99 (0.01) 0.65 (0.03) 0.58 (0.04) 1.00 (0.00)
MAR enabled 0.91 (0.03) 0.82 (0.07) 0.98 (0.01) 0.70 (0.06) 0.55 (0.03) 0.80 (0.10)
P value 0.07 0.78 0.87 0.21 0.37 0.07
In the presence of a root filling
MAR disabled 0.58 (0.05) 0.32 (0.13) 0.83 (0.06) 0.58 (0.09) 0.38 (0.09) 0.87 (0.06)
MAR enabled 0.57 (0.03) 0.38 (0.25) 0.77 (0.25) 0.53 (0.06) 0.45 (0.26) 0.73 (0.21)
P value 0.77 0.75 0.67 0.43 0.69 0.34

Az, area under ROC curve; CBCT, cone-beam computed tomography; MAR, metal artifact reduction.

Freitas et al. 2018). The image noise was quantified
by measuring the standard deviation of mean grey
value (Freitas et al. 2018, Queiroz et al. 2018). High
standard deviation means high image noise, which is
supposed to be well discerned in homogeneous struc-
tures. There was no decrease in image noise when
the MAR tool was enabled, as opposed to Bezerra
et al. (2015) who evaluated the images created by the
Picasso Trio CBCT system using teeth with metal
posts, which have a higher atomic number than root
filling materials. Again, it can be inferred that the
MAR tool is not effective in the presence of lower
quantity of artefacts. Moreover, comparing CBCT sys-
tems, the Picasso Trio had greater image noise than
OP300, except for the trabecular region, which can
be explained by the fact that trabecular bone is a

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 5
 MAR in the diagnosis of fractured instrument Costa et al.

Table 2 Mean values of standard deviation (SD) of trabecu- images (Rosen et al. 2016, Ramos Brito et al. 2017).
lar and cortical bone, and soft tissue regions of root filled Also, the main objective of the present study was to
teeth with fractured files in situ when using MAR tool dis- evaluate the use of the MAR tool, which is only avail-
abled and enabled
able for CBCT images.
CBCT system In order to approximate clinical conditions, all sim-
ulations of this laboratory study were performed on a
OP300 Picasso Trio
MVSD MVSD dry jaw with soft tissue simulation responsible for
producing secondary radiation. Besides that, various
Trabecular bone
MAR disabled 335.5 (61.4) 255.9 (42.1)
types of endodontic instruments used in clinical prac-
MAR enabled 327.2 (61.2) 256.3 (45.4) tice, including stainless steel and NiTi files (Rosen
P value 0.26 0.97 et al. 2014), as well as reciprocating system were
Cortical bone evaluated. Despite these efforts, it is recognized that
MAR disabled 84.9 (15.8) 118.9 (33.7)
laboratory studies do not simulate clinical conditions
MAR enabled 84.2 (17.4) 113.7 (29.0)
P value 0.81 0.48
accurately nor provide a patient history or symptoma-
Soft tissue tology.
MAR disabled 48.5 (9.3) 55.9 (7.9)
MAR enabled 46.8 (4.8) 63.1 (10.4)
P value 0.54 0.06 Conclusion
CBCT, cone-beam computed tomography; MAR, metal artefact
The MAR algorithm did not influence the detection of
reduction; MVSD, mean value of standard deviation.
fractured endodontic instruments in both unfilled and
filled root canals of extracted teeth. Therefore, due to
an increase in image reconstruction time, the use of
heterogeneous structure that may obscure the varia- the MAR tool is not routinely recommended for this
tion in image noise when using different systems. specific clinical situation with these two devices,
However, CBCT units were not compared because sev- Picasso Trio and OP300.
eral factors contribute to the final image quality
besides the action of the MAR tool.
Another factor that can influence image quality is Acknowledgements
the voxel size, which can range from 0.085 to
0.4 mm, depending on the technical specifications of The authors thank the Coordenacßa ~o de Aperfeicßoa-
each CBCT apparatus (Rosen et al. 2016, Kocß et al. mento de Pessoal de Nıvel Superior – Brasil (CAPES)
2018). Although smaller voxel sizes act to improve – Finance Code 001 for the financial support and the
the spatial resolution thus providing more detail in Espacßo da Escrita (Writing Center) at the University of
the image (Cebe et al. 2017), a higher dose of radia- Campinas (UNICAMP) for the language services.
tion is necessary to generate high-quality images
(Venskutonis et al. 2014). A previous study reported Conflict of interest
that larger voxels did not interfere in the diagnostic
accuracy of fractured instruments detection (Ramos The authors have stated explicitly that there are no
Brito et al. 2017); therefore, a 0.2 mm voxel was conflicts of interest in connection with this article.
used in the present study.
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