BASIC RESEARCH – TECHNOLOGY
Victor Aquino Wanderley, DDS, MSc,*
Eduarda Helena Leandro Nascimento,
†‡
DDS, MSc, PhD, Hugo Ga^eta-Araujo,
DDS, MSc, PhD,* Christiano Oliveira-
Santos, DDS, MSc, PhD,*§
Deborah Queiroz Freitas, DDS, MSc,
PhD,* and Matheus L. Oliveira, DDS, MSc,
PhD*
SIGNIFICANCE
Artifacts in CBCT imaging are
differently projected depending
on the spatial orientation of the
object. The combined
assessment of 2 CBCT
volumes obtained with the
tooth of interest at different
orientations favors the
detection of vertical root
fracture.
From the *Division of Oral Radiology,
Department of Oral Diagnosis, Piracicaba
Dental School, University of Campinas,
Piracicaba, Sa ~o Paulo, Brazil;
†
Department of Clinical and Preventive
Dentistry, Federal University of
Pernambuco, Recife, Pernambuco, Brazil;
‡ challenge for the dental practitioner, and the examinations most commonly used for imaging evaluation of
Division of Oral Radiology, Department of
Dentistry, Federal University of Sergipe
(UFS), Aracaju-SE, Brazil; and
§
Department of Stomatology, Public Oral
Health, and Forensic Dentistry, School of
Dentistry of Ribeir~ao Preto, University of
Sa~o Paulo, Ribeira ~o Preto, Brazil.
Address requests for reprints to Dr Victor
Aquino Wanderley, Av Limeira, 901,
~o Piracicaba, SP, Brazil 13414-903.
Areia
E-mail address: victoraquinow@gmail.
com
0099-2399/$ - see front matter
Copyright © 2021 American Association
of Endodontists.
https://doi.org/10.1016/
j.joen.2021.04.001
1132 Wanderley et al.
Combined Use of 2 Cone-
beam Computed Tomography
Scans in the Assessment of
Vertical Root Fracture in Teeth
with Intracanal Material
ABSTRACT
Introduction: The purpose of this preliminary study was to evaluate the diagnostic accuracy
of the combined use of 2 cone-beam computed tomographic (CBCT) volumes obtained with
the tooth of interest positioned at different orientations in the detection of vertical root fracture
(VRF). Methods: Thirty single-rooted teeth were divided into 2 main groups (n 5 15): control
and with VRF. The teeth were individually placed in a phantom composed of a human skull
and mandible, which was CBCT scanned in 2 spatial orientations: conventional (with the
Frankfurt plane parallel to the floor) and angled acquisition (tilted 90 backward). Also, each
tooth was scanned with gutta-percha, a metal post, and without any intracanal material. Three
oral radiologists individually evaluated the images resulting from conventional acquisition and
verified the presence or absence of VRF (conventional CBCT assessment), setting a score on
a 5-point scale. Subsequently, the observers evaluated both images resulting from the
conventional and angled acquisitions (combined CBCT assessment). The diagnostic values of
the conventional and combined assessments were compared using 2-way analysis of
variance with the post hoc Tukey test. The significance level was set at 5% (a 5 0.05).
Results: The combined CBCT assessment showed higher accuracy and sensitivity in the
VRF diagnosis of teeth filled with gutta-percha (P , .05). In teeth with a metal post, all
diagnostic values were higher in the combined CBCT assessment (P , .05).
Conclusions: This preliminary study suggests that the CBCT-based diagnosis of VRF in
teeth with intracanal material was improved when the assessment combines images obtained
at 2 orientations. (J Endod 2021;47:1132–1137.)
KEY WORDS
Artifact; cone-beam computed tomography; diagnosis; endodontics; tooth fractures
Vertical root fractures (VFRs) often occur in teeth with endodontic treatment1. Their diagnosis is a
this condition (periapical radiography and cone-beam computed tomography [CBCT] imaging) present
important limitations that can hinder the fracture line view. As a consequence, low diagnostic values
related to VRF detection in filled teeth are reported2,3.
The limited performance of periapical radiographs in these cases can be attributed to the
overlapping of structures inherent to the image formation process such that additional radiographs
acquired with different angulations can improve the detection of VRF4,5. On the other hand, even though
CBCT imaging allows for 3-dimensional evaluation of the structures, it has as a disadvantage the
formation of artifacts when high-density materials are present, such as gutta-percha and intracanal metal
posts 22. According to the geometric projection of the X-ray beam, these objects cause artifacts in the
form of lines and dark bands mimicking VRFs6.
In an attempt to reduce the influence of the artifacts and improve the performance of CBCT
imaging in the diagnosis of VRF, previous studies have modified energetic parameters6,7, voxel size3,5,
and image filters3,8 and found little contribution for filled teeth, mainly with metal posts2. Recently, the
variation of tooth orientation for CBCT image acquisition was also investigated, and, despite the
JOE  Volume 47, Number 7, July 2021
subjective noticeable change in the pattern of
artifact formation, this was not enough to
improve the diagnosis of VRF9.
Considering that the variation of the
tooth orientation before the CBCT scan
causes a change in the pattern of artifact
formation9 and that the diagnostic process is
complex and can benefit from the increased
amount of information available, it was
hypothesized that the combined assessment
of CBCT volumes obtained with the tooth at
different orientations could favor the diagnosis
of VRF. Therefore, the purpose of this
preliminary study was to evaluate the
diagnostic accuracy of the combined use of 2
CBCT volumes obtained with the tooth of
interest at different orientations in the detection
of VRF.
MATERIALS AND METHODS
The present study was approved by the local
institutional research ethics committee (CAAE
57793316.4.0000.5418). The sample was
composed of 180 CBCT volumes obtained
from a previously published methodology9.
Each CBCT volume had 1 endodontically
instrumented dental root of interest inserted
into the alveolar socket of a phantom
composed of a dry human skull and mandible.
The total sample was arranged in 12 groups of
15 CBCT volumes according to the orientation
of the longitudinal axis of the dental root of
interest (perpendicular or parallel to the
projection plane of the X-rays), the intracanal
filling condition (no filling, gutta-percha, and
metal post), and the fracture condition (absent
or present). Figure 1A and B shows a
representative VRF used in this study and the
resulting CBCT image, and Figure 2 illustrates
the composition of the experimental groups.
The CBCT scans were performed using the
Picasso Trio unit (Vatech, Gyeonggi-do,
Republic of Korea) with a field of view of 5 ! 5
cm, a 0.2-mm voxel size, 85 kVp, and 5 mA.
Three oral radiologists with over 5 years
of experience in CBCT imaging individually
evaluated the presence or absence of root
fracture. For each root, the CBCT volume
obtained with the longitudinal axis of the dental
root of interest perpendicular to the projection
plane of the X-rays was assessed
(conventional CBCT assessment). Immediately
after, the same CBCT volume was assessed in
combination with that obtained with the
longitudinal axis of the dental root of interest
parallel to the projection plane of the X-rays
(combined CBCT assessment). The presence
or absence of root fractures was registered
using a 5-point scale as follows: 1, definitely
absent; 2, probably absent; 3, uncertain; 4,
probably present; and 5, definitely present.
JOE  Volume 47, Number 7, July 2021
Thus, each observer assigned 2 scores for
each root: 1 score based on the conventional
CBCT assessment and the other score based
on the combined CBCT assessment (Fig. 3).
The OnDemand 3D software
(Cybermed Inc, Tustin, CA) was used to
evaluate the images in a low-light environment
with a 24.1-inch flat screen monitor with 1920
! 1080 pixel resolution (MDRC-2124; Barco
NV, Kortrijk, Belgium). The observers were
encouraged to analyze the CBCT volumes
dynamically (axial, coronal, and sagittal
reconstructions) with the possibility of
adjusting brightness, contrast, zoom, and
rotation settings. After 30 days, 25% of the
sample was reevaluated to test intraobserver
reproducibility.
Statistical analysis was performed using
Prism 8.0.1 (GraphPad Software, San Diego,
CA). The weighted kappa value was used to
assess intra- and interobserver agreement
considering the following level of agreement:
,0.40, poor; 0.40–0.59, moderate; 0.60–
0.74, good; and 0.75–1.00, excellent10. The
diagnostic tests of sensitivity, specificity,
accuracy, area under the receiver operating
characteristic curve (Az), positive predictive
value (PPV), and negative predictive value
(NPV) were calculated for both conventional
and combined CBCT assessments for the
different intracanal conditions. Two-way
analysis of variance with the post hoc Tukey
test was used to compare the diagnostic tests
for both assessments in the different intracanal
conditions. The significance level was set at
5% (a 5 0.05).
RESULTS
Diagnostic values of accuracy, sensitivity,
specificity, Az, PPV, and NPV are shown in
Table 1. Accuracy related to the conventional
CBCT assessment was statistically higher in
the absence of filling material followed by the
presence of gutta-percha and a metal post
(P , .01). For the combined CBCT
assessment, accuracy was also higher in the
absence of filling material than in the presence
of gutta-percha and a metal post (P , .01),
which did not differ statistically from each other
(P 5 .71). The sensitivity for both CBCT
assessment methods was statistically higher
for no filling (P , .01), and there was no
difference between gutta-percha and a metal
post (P . .05). Specificity for the combined
CBCT assessment was not significantly
different for the intracanal conditions tested
(P . .05). Az, PPV, and NPV in the
conventional CBCT assessment were
statistically higher in the absence of filling
material followed by the presence of gutta-
percha and a metal post (P , .05). In the
combined CBCT assessment, Az, PPV, and
NPV were also higher in the absence of filling
material than in the presence of gutta-percha
and a metal post (P , .05), which did not differ
statistically from each other (P . .05).
The combined CBCT assessment
method did not improve the diagnostic values
for teeth without intracanal material (P . .05).
However, in the combined CBCT assessment
of teeth, gutta-percha, accuracy, sensitivity,
Az, PPV, and NPV presented significantly
higher values than those in the conventional
assessment (P , .05). In teeth with a metal
post, all diagnostic tests were significantly
higher in the combined than in the conventional
CBCT assessment (P , .05).
As shown in Table 2, in the absence of
intracanal material, intraobserver agreement
was excellent (0.85–1.00) in the combined
assessment and ranged from moderate (0.57)
to excellent (0.97) in the conventional
assessment; interobserver agreement ranged
from good to excellent in both conventional
(0.72–0.86) and combined (0.71–0.84)
assessments. In the presence of gutta-percha
and a metal post, increased intra- and
interobserver agreement values were
observed in the combined assessment.
Intraobserver agreement in the conventional
assessment of teeth with gutta-percha ranged
from poor (0.21) to moderate (0.53) and, when
a metal post was present, ranged from poor
(0.33) to good (0.61). Interobserver agreement
in the conventional assessment of teeth with
gutta-percha ranged from moderate (0.48) to
good (0.63) and, when a metal post was
present, ranged from poor (0.14) to moderate
(0.50). In the combined assessment of teeth
with gutta-percha, intraobserver agreement
ranged from moderate (0.40) to good (0.67)
and, when a metal post was present, ranged
from good (0.61) to excellent (0.76).
Interobserver agreement ranged from
moderate to excellent in the combined
assessment of teeth with gutta-percha (0.48–
0.81) or a metal post (0.40–0.75).
DISCUSSION
The detection of VRF using CBCT imaging is
challenging. Although CBCT allows for
volumetric evaluation, there is no agreement
on its efficiency in detecting VRF in the
presence of high-density materials, such as
hyperdense endodontic materials11,12.
Interestingly, the present study revealed an
increase in accuracy, sensitivity, and specificity
when jointly assessing CBCT images obtained
with the longitudinal axis of the root of interest
perpendicular and parallel to the projection
plane of the X-rays. Despite this, for being a
CBCT Scans in the Assessment of VRF 1133
FIGURE 1 – Photograph (A ) and CBCT axial reconstruction (B ) of a representative vertical root fracture (arrow ) used in this study.
preliminary study, caution is needed for clinical
application.
Wanderley et al9 conducted a study in
which the long-axis orientation of the tooth
was modified in relation to the X-ray projection
plane to verify if there would be an
improvement in the diagnosis of VRF in teeth
with intracanal material and concluded that
there is no difference in this diagnosis.
However, because the CBCT images were
independently and randomly assessed, the
observers were not able to add any previous
information of the same root. In the present
study, the observers had the opportunity to
assess the same root in both orientations,
being aware it was the same root, to establish
the diagnosis. In the combined CBCT
FIGURE 2 – A flow diagram showing the composition of the experimental groups.
1134 Wanderley et al.
assessment, an improvement in the accuracy,
sensitivity, specificity, Az, PPV, and NPV was
observed. The increase of the diagnostic
values in the combined CBCT assessment
may be related to the different artifact patterns
that the images present; when combining
information, a questionable diagnosis in the
conventional CBCT assessment may have
become a certainty in the combined CBCT
assessment.
The change in orientation of teeth with
intracanal material in the acquisition of CBCT
imaging alters the pattern of artifact formation.
The difference in the artifact pattern between
the conventional and angled acquisitions is
easily perceived. In the conventional
acquisition, the artifact streaks are oriented in
several directions in the axial plane, impairing
the detection of the fracture, and in the angled
position the artifact is restricted to a horizontal
band, facilitating the visualization of fractures
that are located above and under this
horizontal band. Then, based on the proposed
methodology, when it is not possible to
visualize VRF in a tooth with intracanal material
in the conventional CBCT acquisition, a
combined assessment with another CBCT
acquisition obtained at a modified orientation
may facilitate it.
Several studies have demonstrated that
the CBCT-based diagnosis of root fracture in
teeth with a metal post remains challenging
when using the conventional CBCT
assessment2,6,13. However, in the present
JOE  Volume 47, Number 7, July 2021
FIGURE 3 – CBCT reconstructions of a representative fractured root of interest with 2 intracanal materials (gutta-percha and a metal post) and at 2 assessment conditions (con-
ventional and combined). The arrows indicate the fracture line.

study, a statistically significant improvement difference was observed between the 2 It is important to mention that the
was observed in the accuracy and sensitivity in intracanal materials. Conversely, in the acquisition of 2 CBCT images of the same
the diagnosis of VRF of the same tooth in the absence of endodontic material, no patient increases the radiation absorbed dose.
presence of gutta-percha and a metal post in a improvement was observed in the diagnosis to Thus, the “As Low As Diagnostically
combined CBCT assessment; no statistical justify the use of the present methodology. Acceptable being Indication-oriented and
Patient-specific” (ALADAIP) principle must be
considered to balance the patient’s need and
TABLE 1 - The Diagnostic Values of Accuracy, Sensitivity, Specificity, Area under the Receiver Operating Characteristic the dose of radiation of the radiographic
Curve (Az), Positive Predictive Value, and Negative Predictive Value according to the Cone-beam Computed Tomography examination14. In this sense, this study does
(CBCT) Assessment in Each Intracanal Condition not aim to suggest that 2 images are
mandatory to detect VRF. Instead, our
Intracanal conditions preliminary results suggest that, in specific
Diagnostic CBCT No Gutta- Metal cases when the presence of VRF is suspected
test assessment filling percha post in the conventional CBCT assessment, a
Accuracy Conventional 92.2Aa 67.7Bb 57.8Cb combined CBCT assessment with another
Combined 93.3Aa 76.6Ba 74.4Ba scan obtained with the patient’s head tilted
Sensitivity Conventional 93.3Aa 53.1Bb 46.6Bb back may bring benefits to this diagnosis in
Combined 95.5Aa 71.6Ba 62.2Ba teeth with intracanal material.
Specificity Conventional 91.1Aa 80.5Aa 60.4Bb Because this is an ex vivo study with a
Combined 90.9Aa 80.5Aa 84.3Aa static mounted human skull and mandible, the
Az Conventional 0.94Aa 0.70Bb 0.60Cb
absence of clinical parameters has to be
Combined 0.93Aa 0.79Ba 0.74Ba
considered as a limitation. In addition, the
Positive Conventional 91.3Aa 75.2Bb 60.0Cb
predictive Combined 89.6Aa 82.1Ba 82.4Ba impracticality of positioning the patient’s head
value back in cases of physical restraint, the potential
Negative Conventional 93.2Aa 63.8Bb 56.4Cb discomfort of tilting the head back with an
predictive Combined 95.2Aa 72.5Ba 69.6Ba increased chance of movement artifact
value formation, and the impossibility of
accomplishing this position in some CBCT
Uppercase superscript letters indicate statistically significant differences in the rows (between intracanal conditions).
units should be considered. Furthermore,
Lowercase superscript letters indicate statistically significant differences in the columns (between conventional and
combined CBCT assessments). because this is an initial methodology, more

JOE  Volume 47, Number 7, July 2021 CBCT Scans in the Assessment of VRF 1135
TABLE 2 - Intra- and Interobserver Agreement in the Detection of Vertical Root Fracture for the Different Cone-beam with Picasso Trio (Vatech) because of
Computed Tomography (CBCT) Assessments and Intracanal Conditions numerous parameters and specifications
that affect image quality, namely the sensor
Conventional CBCT Combined CBCT type, energy parameters, X-ray beam
assessment assessment geometry, spatial resolution,
Intracanal
condition Observer 1 2 3 1 2 3 contrast resolution, and reconstructions
algorithms15.
No filling 1 0.92 0.72 0.86 0.93 0.75 0.71
2 0.57 0.83 0.85 0.84 In conclusion, this preliminary study
3 0.97 1.00 suggests that the diagnosis of VRF in teeth
Gutta- 1 0.53 0.63 0.48 0.67 0.81 0.48 with intracanal material was improved when
percha CBCT images obtained at 2 orientations were
2 0.25 0.55 0.40 0.50 assessed in combination. Further investigation
3 0.21 0.57 is needed before broad clinical
Metal post 1 0.33 0.14 0.14 0.73 0.75 0.40 implementation.
2 0.38 0.50 0.61 0.54
3 0.61 0.76

studies should be developed including diverse
angles and positions of the human head
phantom, CBCT units, and anatomic regions,
in addition to evaluating the effective dose in
sensitive anatomic regions for both the
conventional and angled positions before
clinical application in patients.
Despite the similarity among some
CBCT units, caution is needed when
extrapolating the present results obtained
ACKNOWLEDGMENTS
Supported in part by the Coordenaça ~o de
Aperfeiçoamento de Pessoal de Nível
Superior, Brazil (finance code 001).
The authors deny any conflicts of
interest related to this study.

REFERENCES
1. Liao WC, Tsai YL, Wang CY, et al. Clinical and radiographic characteristics of vertical root
fractures in endodontically and nonendodontically treated teeth. J Endod 2017;43:687–93.

2. Neves FS, Freitas DQ, Campos PS, et al. Evaluation of cone-beam computed tomography in the
diagnosis of vertical root fractures: the influence of imaging modes and root canal materials. J
Endod 2014;40:1530–6.

3. De Martin E Silva D, Campos CN, Pires Carvalho AC, et al. Diagnosis of mesiodistal vertical root
fractures in teeth with metal posts: influence of applying filters in cone-beam computed
tomography images at different resolutions. J Endod 2018;44:470–4.

4. Malhotra N, Kundabala M, Acharaya S. A review of root fractures: diagnosis, treatment and

prognosis. Dent Update 2011;38:615–28.

5. da Silveira PF, Vizzotto MB, Liedke GS, et al. Detection of vertical root fractures by conventional
radiographic examination and cone beam computed tomography - an in vitro analysis. Dent
Traumatol 2013;29:41–6.
6. Ga^
eta-Araujo H, Silva de Souza GQ, Freitas DQ, et al. Optimization of tube current in cone-beam
computed tomography for the detection of vertical root fractures with different intracanal
materials. J Endod 2017;43:1668–73.
7. Pinto MG, Rabelo KA, Sousa Melo SL, et al. Influence of exposure parameters on the detection of
simulated root fractures in the presence of various intracanal materials. Int Endod J 2017;50:
586–94.
8. Ferreira LM, Visconti MA, Nascimento HA, et al. Influence of CBCT enhancement filters on
diagnosis of vertical root fractures: a simulation study in endodontically treated teeth with and
without intracanal posts. Dentomaxillofacial Radiol 2015;44:20140352.
9. Wanderley VA, Freitas DQ, Haiter-Neto F, et al. Influence of tooth orientation on the detection of
vertical root fracture in cone-beam computed tomography. J Endod 2018;44:1168–72.

10. Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized
assessment instruments in psychology. Psychol Assess 1994;6:284–90.

11. Chang E, Lam E, Shah P, et al. Cone-beam computed tomography for detecting vertical root
fractures in endodontically treated teeth: a systematic review. J Endod 2016;42:177–85.
12. Talwar S, Utneja S, Nawal RR, et al. Role of cone-beam computed tomography in diagnosis of
vertical root fractures: a systematic review and meta-analysis. J Endod 2016;42:12–24.

1136 Wanderley et al. JOE  Volume 47, Number 7, July 2021

 13. Melo SL, Haiter-Neto F, Correa LR, et al. Comparative diagnostic yield of cone beam CT
reconstruction using various software programs on the detection of vertical root fractures.
Dentomaxillofac Radiol 2013;42:20120459.

14. Oenning AC, Pauwels R, Stratis A, et al., Dimitra Research Group. Halve the dose while
maintaining image quality in paediatric cone beam CT. Sci Rep 2019;9:5521.

15. ^ta-Araujo H, Alzoubi T, Vasconcelos KF, et al. Cone beam computed tomography in
Gae
dentomaxillofacial radiology: a two-decade overview. Dentomaxillofac Radiol
2020;49:20200145.

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