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EGYPTIAN Vol. 65, 663:671, April, 2019
DENTAL JOURNAL I.S.S.N 0070-9484

w w w. e d a - e g y p t. o r g

THE ACCURACY OF INTRA-ORAL DIGITAL RADIOGRAPHY VERSUS

THE STATE-OF-ART ULTRA-LOW DOSE CONE BEAM COMPUTED
TOMOGRAPHY PROTOCOL IN THE DETECTION OF HORIZONTAL
ROOT FRACTURES. A DIAGNOSTIC ACCURACY STUDY

Maha Sayed Mohamed* , Salma Belal Eiid* , Dina Mohamed El Beshlawy*

and Sahar Hosny El Dessouky*

ABSTRACT
Objectives: The purpose of this study was to compare the intraoral periapical radiographic
techniques (parallel and bisecting techniques) and the ULD CBCT protocol for their detection
capabilities of simulated horizontal root fractures with different angles.

Methodology: 195 extracted incisors were divided into three equal groups of 65 teeth each.
Artificially simulated incomplete HRF were prepared in two groups with two different angulations
(75° & 45°), and at two different locations (cervical and middle) by using a separating disk,
where the third group was the control group. Positioning of the teeth was randomly undertaken
in the sockets of a dry human skull and mandible, and then imaged using the three radiographic
techniques. For qualitative analysis, sensitivity, specificity, and test diagnostic accuracy were
calculated. For quantitative assessment, Dahelberg error (DE) and Bland and Altman Limits of
Agreements (LOA) were applied. For inter and intra-observer reliability analysis, kappa measure of
inter-rater agreement and Intra-class Correlation Coefficients (ICC) were calculated.

Results: The ULD CBCT has the highest sensitivity, specificity and diagnostic accuracy for
detecting HRF at any angle and location. Regarding the accurate determination of the oblique
course of fracture lines, the intraoral radiographic techniques showed a very low concordance
compared to ULD CBCT. The magnitude of absolute measurement error for the whole set of teeth
was 1.89° with no statistical significant difference, 95% CI (-5.09 – 5.41). Additionally, very good
to excellent inter and intra-observer agreement was perceived when considering the measurement
of the simulated HRF angulation (0.78 - 0.99).

Conclusion: The ULD CBCT imaging protocol of Planmeca Promax 3D Mid was the best
modality for detection and localization of HRF with high validity and reliability in angular
measurement assessment.

KEY WORDS: Intraoral radiography, PSP, ULD CBCT, Horizontal root fractures.

* Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University, Egypt
(664) E.D.J. Vol. 65, No. 2
INTRODUCTION
Horizontal root fracture (HRF) is one of the
consequences of dental trauma, where the fracture
line extends across the long axis of the root either
transversely or obliquely. These fractures usually
involve single-rooted permanent teeth with a wide
variety of presentations concerning the location,
angulations, and severity. Correct diagnosis and
localization of root fracture position are of utmost
importance in dental practice 1 2 3.
Traditionally, the radiographic examination of
HRF relied on intra-oral radiography (IOR) because
of its low cost, convenience, and high resolution.
However, it depends mainly on the relative
angulation of the incident x-ray beam to the fracture
plane and their inherent 2D limitations may result in
a total concealment of the fracture line. Additionally,
a risk of misdiagnosing the location and course of
the root fracture is highly probable 4.
Recently, the use of CBCT for the diagnosis of
HRFs has been endorsed repeatedly to avoid the
misdiagnosis of fractures with concurrent improper
treatment and unfavorable outcomes. CBCT with
its adjustable FOV feature, directly correlated to the
effective doses delivered to patients, has become the
recommended technology in the clinical practice.
Although, this is a major step forward in the field
of dose optimization, the radiation dose delivered
is still higher than conventional radiography, and
should be used cautiously 5&6.
Interestingly, a revolutionary ultra-low dose
(ULD) CBCT protocol has been released by
Planmeca Promax 3D Mid, which is reported to
reduce the effective patient dose by an average
of 77% in comparison to other CBCT protocols 7.
However, very few studies showed the effectiveness
of this state-of-the-art in the field of dentistry. Hence,
the current study was performed in order to assess the
accuracy of ULD CBCT imaging protocol compared
with the most prevalent intraoral techniques used in
clinics (bisecting angle and paralleling techniques)
Maha Sayed Mohamed, et al.
for the detection and localization of the simulated
HRF.
MATERIALS AND METHODS
This study was undertaken after the approval of
the research committee of the Faculty of Dentistry,
Cairo University. A sample size of 195 extracted
permanent maxillary and mandibular incisors
(80 maxillary and 115 mandibular incisors) with
intact roots that had never undergone root canal
treatment were used. The sample size calculation
was performed using the nQuery statistical package
to achieve a power of 80%, and a significance level
of 5% based on the primary objective, which was
the detection of simulated HRF. Teeth with root
resorption, cracks or dental root fractures were
excluded.
Sample Preparation
All teeth were cleaned from any calculus deposits
using an ultrasonic scaler, disinfected with diluted
sodium hypochlorite (NaOCl) solution for 1 week,
and stored in distilled water to avoid desiccation
and cracking 8. The teeth were allocated randomly
into 3 equal groups of 65 teeth each:
Group A: with an artificial groove at the level of
the cervical third of the root forming an angle of 75°
with the long axis of the tooth 9&10.
Group B: with an artificial groove at the level
of the middle third of the root forming an angle of
45° with the long axis of the tooth (traversing the
cervico-middle area) 9&10.
Group C (Control group): with intact roots.
Open source web-based software (http://www.
random.org/sequences/) was used to randomly code
all the teeth used in the study into 3 equal groups (A,
B, and C) with unpredicted numbers.
To standardize the grooves’ angulations, a line
was drawn on the mesial or distal surfaces of the
root, extending from the incisal tip towards the
THE ACCURACY OF INTRA-ORAL DIGITAL RADIOGRAPHY VERSUS
apex representing its long axis. Then, a protractor
and a ruler were overlapped to adequately imitate
the desired angles, and the grooves were prepared
accordingly. The teeth in the groups (A and B) were
grooved until the pulp chamber was reached using
the separating edge coated double-sided diamond
disk of 0.2 mm thickness (BPBYKK, China) and a
low speed micro-motor (NX-201 N, Korea) [Fig.1].
Fig. (1) Simulated HRF during preparation.
A dry human maxilla and mandible were
covered by 9 layers of pink wax (approximately
13 mm thickness) labially to simulate the hu-
man soft tissues attenuation properties as rec-
ommended by Schropp et al., 2012. The lingual
and palatal surfaces were covered by 2 layers
of pink wax (about 3 mm in thickness). Groups
of 3-4 incisors were placed within the anterior
sockets of the dry human skull and mandible.
The roots were covered by inlay wax (774 Veco
Dent Co, Italy) to simulate the periodontal liga-
ment space.
Test Methods
The reference standard in this study was
the visual assessment of the simulated HRFs
(grooves) on the extracted teeth and the angular
measurements using the protractor-ruler com-
bination.
(665)
The human dry skull and mandible contain-
ing the teeth were imaged using:
a) Cone beam Computed Tomography imaging
CBCT scans were taken using Ultra Low
Dose imaging protocol of Planmeca Promax
3D MID machine (90 kVp - 5.6 mA- 4 sec scan
time - 40×50 mm FOV- 0.2 mm voxel size).
b) Digital Periapical Imaging
The digital system used was the Soredex Digora
Optime and all images were acquired using the
dental x-ray machine (Soredex, Nahkelantie, 160,
F1-04301) and a PSP plate of size 2 (41×31 mm).
The digital periapical images were operated at 70
kVp- 8 mA- 0.08 sec exposure time.
The skull and mandible were adjusted to simulate
the normal human position during exposure with the
PSP stabilized using adhesive tapes.
This setup was imaged twice by a single
radiologist using the paralleling and bisecting
angle techniques. The paralleling technique was
performed using an X-Ray film holder (Rinn XCP,
United Kingdom), and the bisecting technique was
conducted at an angle of +50° for maxillary incisors
and -25° for mandibular incisors.
Image Analysis
Two oral and maxillofacial radiologists of
different experiences (5 and 10 years) evaluated the
images independently. The whole image analysis
procedures were performed twice by one evaluator
with 2 weeks interval separating the analysis
sessions.
The CBCT scans were reviewed using the
Planmeca Romexis software version 4.6.2.R. The
slice thickness was decreased to 0.2 mm for the
detection of simulated HRF. In the multi-planar
reformation (MPR) window, the three MPR images
(axial, coronal and sagittal) were used to detect
(666) E.D.J. Vol. 65, No. 2
the HRF by using a binary scale (Yes/No), where
the fracture was defined as a thin radiolucent line
extending along the roots of teeth. If a groove was
identified, evaluators shift to the corrected oblique
sagittal cut to ascertain the location of the fracture
[Fig. 2]. Then, the angular measurement between
the detected radiolucent line and the long axis of the
tooth was done on the sagittal cut of 1.8 mm slice
thickness using the Romexis 4.6.2.R software built-
in angular measuring tool.
Fig. (2) (A) Corrected CBCT coronal image of 11 with an
incomplete HRF fracture at the middle third (short arrow)
(B) Corrected CBCT sagittal image demonstrating the
fracture extension from the middle third of the root to
the cervical third palatally (long traversing arrow), and
(C) Corrected CBCT sagittal image demonstrating the
angular measurement between the detected radiolucent
line (yellow line) and the long axis of the tooth.
Digital periapical images were exported from
the Digora software (Windows 2.8 Soredex)
to a PowerPoint slide show for consecutive
assessment. For complete blinding of the technique
under investigation, an equal cropping for the
incisal parts containing the film-holder print was
intentionally performed by a colleague not sharing
in this research, and a random number sequence was
generated from the website (http://www.random.
org/sequences/) randomizing the 162 images to
avoid memorization bias. Therefore, each evaluator
was blinded regarding the technique, code of the
tooth, the location and angulation of the simulated
fracture. Moreover, the evaluators were blinded to
Maha Sayed Mohamed, et al.
the results of each other, as each evaluator observed,
interpreted and recorded the results independently.
An affirmative diagnosis was given upon
visualization any of the radiographic features
of HRF (sharp radiolucent line, poorly defined
radiolucent line, two radiolucent lines, and an
ellipsoid appearance) 11. Thereafter, the level of the
fracture line was registered.
Statistical Analysis
Data were collected, tabulated and subjected to
statistical analysis using SPSS (version 17). For
qualitative analysis, sensitivity, specificity, and
test diagnostic accuracy were calculated with the
95% confidence limits. For inter and intra-observer
reliability analysis, kappa measure of inter rater
agreement was applied.
Significance level is set at p < 0.05. Two tailed
test assumption is applied through the whole
analysis. For quantitative assessment between
CBCT measurements and the real measurements,
Dahelberg error (DE) was used. To measure and
quantify the size of the differences, Bland and
Altman 95% confidence Limits of Agreements
(LOA) were applied. For inter and intra-observer
reliability, Intra-class Correlation Coefficients
(ICC) including the 95% confidence limits of the
coefficient was calculated.
The data collected from the parallel and bisecting
techniques were collectively added to statistically
assess the synergistic effect of using more than
one vertical angle in the detection of fractures (the
combined protocol).
RESULTS
The current study showed that the ULD CBCT
imaging protocol has the highest sensitivity,
specificity and diagnostic accuracy for detecting
HRF at any angle and location. Regarding the
THE ACCURACY OF INTRA-ORAL DIGITAL RADIOGRAPHY VERSUS (667)

intraoral radiographic techniques, there was no TABLE (2) Comparison between the real measure-
difference between the radiographic detection ments and ULD CBCT angular measure-
of HRF of the bisecting angle technique and ments
the combined conventional protocol, where no
LOA
synergistic effect was acknowledged by using 95%
different vertical angles. The least performance was Confidence
attributed to the paralleling technique as shown in Lower Upper
Mean SD DE MD SD
Table 1. limit limit

Whole set Ref 58.94 13.24

1.89 - 0.16 2.68 -5.09 5.41
of teeth Measured
TABLE (1) Sensitivity, specificity, and diagnostic 59.10 12.42
Cervical
accuracy with 95% confidence interval Ref 71.66 4.23
root
(CI) for the detection of HRF by different fracture
1.78 0.9 2.37 -5.54 3.75
Measured 70.77 4.53
radiographic modalities: (75°)
Middle
Ref 46.22 2.56
root
Test 2 -1.21 2.57 -3.81 6.25
Sensitivity Specificity fracture
Accuracy Measured 47.43 3.71
95% CI 95% CI (45°)
95% CI

Bisecting 86.1 100.0 90.7

technique 0.80 2- 0.920 1.000 –1.000 0.867 - 0.948 As shown in table (2), the ULD CBCT didn’t
show a uniform pattern, there was over-and-
Paralleling 46.9 100.0 64.6
technique 0.383 – 0.555 1.000 –1.000 0.579 - 0.713
under-estimation of the measurements within the
same sample. The Bland & Altman (LOA) was
Combined 86.1 1.000 90.7
performed to show whether there was a significant
technique 0.802 – 0.920 1.000 –1.000 0.867 - 0.948
difference between the mean differences. The test
ULD 100.0 100.0 100.0 failed to prove any significance between the real
CBCT 1.000 – 1.000 1.000 –1.000 1.000 –1.000
measurements and CBCT measured angles.
The evaluation of fracture location concordance The inter-observer and intra-observer agreement
in all teeth when compared to the gold standard in the detection of HRF was very good in all exam-
showed the highest concordance with ULD CBCT ined modalities (0.90 - 1). Considering the measure-
(100%). On the other hand, the use of the combined ments, the results revealed a very good to excellent
conventional protocol or the individual bisecting inter and intra-observer agreement (0.78 - 0.99).
angle technique or paralleling technique showed
DISCUSSION
correct diagnosis in only 56.2%, 49.2%, and 33.8%
of the cases, respectively. The diagnostic procedures in a case of a
suspected HRF should include a comprehensive
Upon comparing the ULD CBCT angular mea-
clinical and radiographic evaluation. The
surements to the direct measurements, the mag- radiographic examination of HRF has traditionally
nitude of absolute measurements error (DE) was relied on IOR but it showed multiple drawbacks
1.89° for the whole set of teeth, 1.78° for the cer- when considering diagnostic capability. One of the
vical group, and the greatest error was 2° for the important but daunting factors during assessment of
middle group (Table 2). HRF, is the determination of the exact location of
(668) E.D.J. Vol. 65, No. 2
the fracture line 12. Multiple guidelines have been
recognized with multiple periapical projections for
the assessment of teeth fractures, but no consensus
was established 3,13, 14. Additionally, a systematic
review conducted by Kullman and Al Sane in
2012, declared that there is a lack of evidence and
lack of specific recommendations regarding which
radiographic methods should be used with dento-
alveolar trauma cases. However, it was suggested
that for obtaining optimal imaging in a traumatized
dental area, two different vertical and three different
horizontal angles should be used 15.
The introduction of CBCT has created new
diagnostic possibilities in dentistry and its use in
the detection of HRF has been increasing constantly
due to the 3D nature of images which allow clear
visualization of fracture line without superimposition,
and thus enables a more specific diagnosis 3,10, 12. In
the last few years, the recommendation of CBCT in
the diagnostic protocol for traumatic teeth injuries
has been increased.
The American Association of Oral and
Maxillofacial Radiologists (AAOMR), the
American Association of Endodontics (AAE),
and the International Association of Dental
Traumatology (IADT) have recommended the use of
CBCT in cases when the conventional radiography
yields inconclusive results or when the fracture is in
the middle third of a root, to determine the oblique
extent of the fracture 3&13.
However, the radiation dose delivered to the
patient is a public health issue and has a great
importance. Currently, in the field of radiology,
the acronym ALADA has taken the ALARA
philosophy one step further, with aiming to
have the best diagnostic quality. Therefore, the
optimization of CBCT protocols is mandatory
to decrease doses delivered to patients with the
provision of the best diagnostic quality 16. As far
as optimization is concerned, CBCT platforms are
continuously evolving and unceasingly providing
new methodologies with lower doses, as the unique
Maha Sayed Mohamed, et al.
mode of the ULD protocol, which was tested in this
study.
In this study in hand, simulation of the HRF
was undertaken by grooving the teeth rather than
fracturing with a hammer, a protocol previously
adopted by Beri and Matariya 2009, and Iikubo et
al 2015. As cited by Avsever et al 2014, and Jones
et al 2015, it is impossible to produce a fracture of
predetermined angles using a hammer, as well as
shattering of teeth into multiples pieces can occur.
The simulation of HRF was made as an incomplete
form because we cannot accurately realign the
fractured segments after sectioning because of tooth
structure removal during preparation 10,13, 17&18.
According to Iikubo et al 2015, there was no
significant difference manifested in the detection
of simulated HRF with different disk thicknesses
(0.15, 0.25& 0.35mm), except for the bisecting
angle technique in cervical fracture when prepared
with the 0.15 vs. 0.35 mm disk thickness10.
Therefore, teeth were grooved using 0.2 mm disk
at one of two levels, either at the middle third of
the root to simulate the real clinical situation, which
is stated to be the most common fracture site or at
the cervical third because it is the one having the
poorest prognosis 19 20 21.
A voxel size of 0.2 mm was chosen as suggested
by Amintavakoli 2013, where no impact on
interpretation was manifested except for voxel
sizes higher than 0.3 mm. With regards to the
conventional radiography, the digital periapical
radiographic system (PSP) used in the current study
was chosen for its valuable merits 22& 23.
During image assessment and detection of HRF
on CBCT scans, the slice thickness was decreased
to 0.2 mm in accordance with Sirin et al 2010
who studied the diagnostic accuracy of CBCT
images in the detection of simulated mandibular
condylar fracture and found that the diagnosis was
more accurate using a slice thickness of 0.2 mm.
For angular measurements, the slice thickness was
increased to 1.8 mm according to the endorsements
THE ACCURACY OF INTRA-ORAL DIGITAL RADIOGRAPHY VERSUS
by Hassan et al 2008, and Moshfeghi et al 2016.
This was in line with our own experience, where
this exact thickness, allowed optimal visualization
of the root apex and crown tip without hampering
the resolution of the simulated fracture 24, 25& 26.
In 2015, Iikubo et al, found that the CBCT has
the highest sensitivity and specificity (100%) in the
detection of simulated HRF regardless the angle
or the location of the fracture line. Moreover, they
stated that the bisecting angle technique (98%) was
more helpful than the paralleling technique (25%) in
the detection of middle root fracture 3. Likewise, in
our study, the ULD CBCT imaging protocol showed
higher performance when compared with the
intraoral bisecting angle and paralleling techniques
in detection and localization of the simulated HRF.
The high success of ULD CBCT imaging protocol in
the detection of the simulated HRF can be explained
due to its 3D imaging capabilities provided by the
different orthogonal planes and this was clearly
stated by several authors as Kamburoğlu et al
2009, Iikubo et al 2015, and Kobayashi-Velasco et
al 2017 3 27 28.
With regard to the IOR techniques, the detection
capability for the middle root fracture was rather
low, this may be due to the oblique course of the
fracture line (45°), which was overshadowed by the
rest of the tooth bulk, making its detection more
difficult than the horizontally oriented fractures.
Moreover, according to Avsever et al 2014,
the root fracture can be visible only in intraoral
radiographs if the central beam is directed within
a maximum range of 15 - 20° vertical angles to the
fracture plane, otherwise, it will be considered a
diagnostic limitation 6.
Interestingly, both conventional techniques
failed to properly determine the exact location of the
cervico-middle group. These results are consistent
with (IADT) Guidelines, May et al 2013, and
Cohenca and Silberman 2017, which suggested
that the cervical root fractures, usually horizontally
oriented, can be detected by paralleling projection,
(669)
however, the root fracture of the middle third, which
has an oblique course frequently misdiagnosed by
using IOR techniques 3&29.
To the best of our knowledge, no studies in
literature investigated angular measurement
accuracy using ULD CBCT. Upon comparing
the CBCT angular measurements to the direct
measurements, our results were considered
clinically acceptable as they didn’t exceed 2° and
were consistent with Lagravère et al 2008, who
found a mean measurement error less than 1 degree
(-0.12 - 0.9°) from the gold standard. Moreover,
it was slightly lower than the results of Moreira
et al 2009, who found that the difference between
the physical and 3D-based angular measurements
ranged from (0.37°- 2.76°) 30, 31, 32&33. The Bland &
Altman (LOA) showed that the difference is expected
with 95% confidence to lie within the upper and
lower limits indicating no statistically significant
difference between the direct measurements and
ULD CBCT scans measurements. However, these
limits (-5.54 - 6.25) are considered clinically wide
and unacceptable, which may be due to the low
power of sample size calculation (80%) in the study.
It’s always highly advocated to do the
measurements more than once and with different
observers, to demonstrate the reliability and
reproducibility of the measuring tool. Results herein
demonstrated a very good to excellent intra-observer
and inter-observer agreements. Likewise, in the
field of orthodontics, Grauer et al 2009, reported
that the overall reliability of angular measurement
and landmark identification on CBCT images has
been ranged from good to very good agreement 34 35.
Considering the agreement in the detection of
HRF, there was a very good inter-observer and intra-
observer agreement in all examined modalities.
According to this study conditions and
limitations, the power of sample size calculation
was based only on the primary outcome, which
might have affected the results of other outcomes
such as the measurements. The diagnostic power
(670) E.D.J. Vol. 65, No. 2
of the study will be highly appreciated with higher
power of sample size calculation (95%).
Among the radiographic modalities studied for
detection and localization of simulated HRF, ULD
CBCT imaging protocol of Planmeca Promax 3D
Mid was the best modality for this task regardless
the fracture line location or angulation. Regarding
the angular measurement capability of ULD
CBCT protocol of Planmeca Promax 3D Mid, it is
considered a reliable tool.
Based on the current study results, we
recommend that whenever an HRF is clinically
suspected, a periapical radiograph with the bisecting
angle technique should be the first diagnostic tool. If
it yields inconclusive results or shows a fracture of
the middle root third, the ULD CBCT scan can be
utilized for better assessment in ruling in of fractures
and evaluating its extension. Moreover, the fact that
most fractures are described, as middle fractures
based on conventional findings should be revisited.
Therefore, future studies using CBCT should be
carried out on traumatized patients to verify the
incidence of cervical, middle and cervico-middle
fractures and correlate the follow up findings with
the long-term prognosis.
REFERENCES
1. Poi WR, Manfrin TM, Holland R, Sonoda CK. Repair char-
acteristics of horizontal root fracture: a case report. Dental
Traumatology. 2002 Mar;18(2):98-102.
2. Zaleckiene V, Peciuliene V, Brukiene V, Drukteinis S. Trau-
matic dental injuries: etiology, prevalence and possible out-
comes. Stomatologija. 2014 Mar 21;16(1):7-14.
3. May JJ, Cohenca N, Peters OA. Contemporary manage-
ment of horizontal root fractures to the permanent denti-
tion: diagnosis—radiologic assessment to include cone-
beam computed tomography. Pediatric dentistry. 2013 Apr
15;35(2):120-4.
4. Kamburoğlu K, Tsesis I, Kfir A, Kaffe I. Diagnosis of arti-
ficially induced external root resorption using conventional
intraoral film radiography, CCD, and PSP: an ex vivo study.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiol-
ogy, and Endodontology. 2008 Dec 1;106(6):885-91.
Maha Sayed Mohamed, et al.
5. Costa FF, Gaia BF, Umetsubo OS, Cavalcanti MG. Detec-
tion of horizontal root fracture with small-volume cone-
beam computed tomography in the presence and absence of
intracanal metallic post. Journal of endodontics. 2011 Oct
1;37(10):1456-9.
6. Saylors C, Warren K. Dose Creep in Dental Radiography.
2017.
7. Liljeholm R, Kadesjö N, Benchimol D, Hellén-Halme K,
Shi XQ. Cone-beam computed tomography with ultra-
low dose protocols for pre-implant radiographic assess-
ment: An in vitro study. Eur J Oral Implantology. 2017 Sep
1;10(3):351-9.
8. Chandki R, Maru R, Gunwal M, Garg A, Mishra A. A com-
parison of different methods for disinfection or sterilization
of extracted human teeth to be used for dental education
purposes. World Journal of Dentistry. 2013 Jan 6;4(1):29-31.
9. Bornstein MM, Wölner-Hanssen AB, Sendi P, Von Arx
T. Comparison of intraoral radiography and limited cone
beam computed tomography for the assessment of root-
fractured permanent teeth. Dental Traumatology. 2009
Dec;25(6):571-7.
10. Iikubo M, Kamio T, Hashimoto N, Nishioka T, Wakoh M,
Sano T, Igarashi C, Kobayashi K, Seki K, Katsumata A,
Ariji E. Comparison of bisecting and parallel intraoral radi-
ography and cone-beam computed tomography for detect-
ing various horizontal angle root fractures. Oral Radiology.
2015 Sep 1;31(3):173-80.
11. White SC, Pharoah MJ. Oral radiology-E-Book: Principles
and interpretation. Elsevier Health Sciences; 2014 May 1.
12. Costa FF, Gaia BF, Umetsubo OS, Pinheiro LR, Torta-
mano IP, Cavalcanti MG. Use of large-volume cone-beam
computed tomography in identification and localization
of horizontal root fracture in the presence and absence of
intracanal metallic post. Journal of endodontics. 2012 Jun
1;38(6):856-9.
13. Avsever H, Gunduz K, Orhan K, Uzun İ, Ozmen B, Egrio-
glu E, Midilli M. Comparison of intraoral radiography and
cone-beam computed tomography for the detection of hori-
zontal root fractures: an in vitro study. Clinical oral investi-
gations. 2014 Jan 1;18(1):285-92.
14. Andreasen JO, Andreasen FM, Andersson L. Textbook and
color atlas of traumatic injuries to the teeth. Oxford: Black-
well Munksgaard; 1993. Vol. 3, pp. 216-256.
 THE ACCURACY OF INTRA-ORAL DIGITAL RADIOGRAPHY VERSUS
15. Kullman L, Al Sane M. Guidelines for dental radiography
immediately after a dento-alveolar trauma, a systematic lit-
erature review. Dental Traumatology. 2012 Jun;28(3):193-9.
16. Ludlow JB, Koivisto J. Dosimetry of Orthodontic Diagnos-
tic FOVs using Low dose CBCT protocols. J Dental Re-
search. 2015;94(Spec Iss A).
17. Jones D, Mannocci F, Andiappan M, Brown J, Patel S. The
effect of alteration of the exposure parameters of a cone-
beam computed tomographic scan on the diagnosis of simu-
lated horizontal root fractures. Journal of endodontics. 2015
Apr 1;41(4):520-5.
18. Beri L, Matariya G. The evaluation of three electronic apex
locators in teeth with simulated incomplete oblique root
fractures. Journal of the International Clinical Dental Re-
search Organization. 2009 Sep 1;1(3):49.
19. Cvek M, Mejàre I, Andreasen JO. Healing and prognosis of
teeth with intra-alveolar fractures involving the cervical part
of the root. Dental Traumatology. 2002 Apr;18(2):57-65.
20. Malhotra N, Kundabala M, Acharaya S. A review of root
fractures: diagnosis, treatment and prognosis. Dental up-
date. 2011 Nov 2;38(9):615-28.
21. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root frac-
tures: the influence of type of healing and location of frac-
ture on tooth survival rates–an analysis of 492 cases. Dental
Traumatology. 2012 Oct;28(5):404-9.
22. Shintaku WH, Venturin JS, Noujeim M, Dove SB. Compar-
ison between intraoral indirect and conventional film-based
imaging for the detection of dental root fractures: an ex vivo
study. Dental Traumatology. 2013 Dec;29(6):445-9.
23. Amintavakoli N. The Effect of Cone Beam CT Voxel Size
on the Identification of Vertical and Horizontal Root Frac-
tures: An In-vitro Study (Doctoral dissertation). 2013.
24. Sirin Y, Guven K, Horasan S, Sencan S, Bakir B, Barut
O, Tanyel C, Aral A, Firat D. The influence of secondary
reconstruction slice thickness on NewTom 3G cone beam
computed tomography–based radiological interpretation
of sheep mandibular condyle fractures. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology, and Endodon-
tology. 2010 Nov 1;110(5):638-47.
25. Hassan B, van der Stelt P, Sanderink G. Accuracy of three-
dimensional measurements obtained from cone beam
computed tomography surface-rendered images for cepha-
lometric analysis: influence of patient scanning position.
View publication stats
(671)
The European Journal of Orthodontics. 2008 Dec 23;
31(2):129-34.
26. Moshfeghi M, Amintavakoli M, Ghaznavi D, Ghaznavi A.
Effect of Slice Thickness on the Accuracy of Linear Mea-
surements Made on Cone Beam Computed Tomography
Images (InVitro). Shahid Beheshti University Dental Jour-
nal. 2016 Jun 15;34(2):100-8.
27. Kamburoğlu K, Ilker Cebeci AR, Gröndahl HG. Effective-
ness of limited cone-beam computed tomography in the
detection of horizontal root fracture. Dental Traumatology.
2009 Jun;25(3):256-61.
28. Kobayashi-Velasco, S., Salineiro, F.C.S., Gialain, I.O. and
Cavalcanti, M.G.P. Diagnosis of alveolar and root fractures:
an in vitro study comparing CBCT imaging with periapi-
cal radiographs. Journal of Applied Oral Science. 2017
Apr;25(2):227-33.
29. Cohenca N, Silberman A. Contemporary imaging for the di-
agnosis and treatment of traumatic dental injuries: A review.
Dental Traumatology. 2017 Oct;33(5):321-8.
30. Tikku T, Khanna R, Maurya RP, Srivastava K, Bhushan R.
Comparative evaluation of cephalometric measurements of
monitor-displayed images by Nemoceph software and its
hard copy by manual tracing. Journal of oral biology and
craniofacial research. 2014 Jan 1;4(1):35-41.
31. Jung PK, Lee GC, Moon CH. Comparison of cone-beam
computed tomography cephalometric measurements using
a midsagittal projection and conventional two-dimensional
cephalometric measurements. The Korean Journal of Ortho-
dontics. 2015 Nov 1;45(6):282-8.
32. Lagravère, M.O., Carey, J., Toogood, R.W., Major, P.W.,
2008. Three-dimensional accuracy of measurements made
with software on cone-beam computed tomography images.
Am. J. Orthod. Dentofac. Orthop. 134, 112–116.
33. Moreira, C.R., Sales, M.A.O., Lopes, P.M.L., Cavalcanti,
M.G.P., 2009. Assessment of linear and angular measure-
ments on three-dimensional cone-beam computed tomo-
graphic images. Oral Surgery, Oral Med. Oral Pathol. Oral
Radiol. Endodontology 108, 430–436.
34. Cançado RH, Lauris JR. Error of the method: what is it for.
Dental press journal of orthodontics. 2014 Apr;19(2):25-6.
35. Grauer D, Cevidanes LS, Proffit WR. Working with DICOM
craniofacial images. American Journal of Orthodontics and
Dentofacial Orthopedics. 2009 Sep 1;136(3):460-70.