Skip to main content

Advertisement

SpringerLink
Log in

Digital subtraction radiography in detection of vertical root fractures: accuracy evaluation for root canal filling, fracture orientation and width variables. An ex-vivo study

  • Original Article
  • Published:
Clinical Oral Investigations Aims and scope Submit manuscript

Abstract

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 0o and ± 10o. 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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Tamse A (2006) Vertical root fractures in endodontically treated teeth: diagnostic signs and clinical management. Endod Top 13:84–94

    Article  Google Scholar 

  2. American Association of Endodontics (2008) Cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures. Endodontics: Colleagues for excellence. http://www.aae.org/uploadedfiles/publications_and_research/endodontics_colleagues_for_excellence_newsletter/ecfesum08.pdf. Accessed 18 June 2019

  3. Holcomb JQ, Pitts DL, Nicholls JI (1987) Further investigation of spreader loads required to cause vertical root fracture during lateral condensation. J Endod 13:277–284

    Article  PubMed  Google Scholar 

  4. Pitts DL, Natkin E (1983) Diagnosis and treatment of vertical root fractures. J Endod 9:338–346

    Article  PubMed  Google Scholar 

  5. Rivera EM, Walton RE (2015) Longitudinal tooth cracks and fractures: an update and review. Endod Top 33:14–42

    Article  Google Scholar 

  6. Cohen S, Blanco L, Berman L (2003) Vertical root fractures: clinical and radiographic diagnosis. J Am Dent Assoc 134:434–441

    Article  PubMed  Google Scholar 

  7. Fuss Z, Lustig J, Tamse A (1999) Prevalence of vertical root fractures in extracted endodontically treated teeth. Int Endod J 32:283–286

    Article  PubMed  Google Scholar 

  8. Bezerra IS, Neves FS, Vasconcelos TV, Ambrosano GM, Freitas DQ (2015) Influence of the artefact reduction algorithm of Picasso trio CBCT system on the diagnosis of vertical root fractures in teeth with metal posts. Dentomaxillofac Radiol 44:20140428

    Article  PubMed  PubMed Central  Google Scholar 

  9. Chen SC, Chueh LH, Hsiao CK, Wu HP, Chiang CP (2008) First untoward events and reasons for tooth extraction after nonsurgical endodontic treatment in Taiwan. J Endod 34:671–674

    Article  PubMed  Google Scholar 

  10. da Silveira PF, Vizzotto MB, Liedke GS, da Silveira HL, Montagner F, da Silveira HE (2013) Detection of vertical root fractures by conventional radiographic examination and cone beam computed tomography - an in vitro analysis. Dent Traumatol 29:41–46

    Article  PubMed  Google Scholar 

  11. de Rezende Barbosa GL, Sousa Melo SL, Alencar PN, Nascimento MC, Almeida SM (2016) Performance of an artefact reduction algorithm in the diagnosis of in vitro vertical root fracture in four different root filling conditions on CBCT images. Int Endod J 49:500–508

    Article  PubMed  Google Scholar 

  12. Makeeva IM, Byakova SF, Novozhilova NE, Adzhieva EK, Golubeva GI, Grachev VI, Kasatkina IV (2016) Detection of artificially induced vertical root fractures of different widths by cone beam computed tomography in vitro and in vivo. Int Endod J 49:980–989

    Article  PubMed  Google Scholar 

  13. Nascimento HA, Neves FS, de Azevedo-Vaz SL, Duque TM, Ambrosano GM, Freitas DQ (2015) Impact of root fillings and posts on the diagnostic ability of three intra-oral digital radiographic systems in detecting vertical root fractures. Int Endod J 48:864–871

    Article  PubMed  Google Scholar 

  14. Kajan ZD, Taromsari M (2012) Value of cone beam CT in detection of dental root fractures. Dentomaxillofac Radiol 41:3–10

    Article  PubMed  PubMed Central  Google Scholar 

  15. Patel S, Brady E, Wilson R, Brown J, Mannocci F (2013) The detection of vertical root fractures in root filled teeth with periapical radiographs and CBCT scans. Int Endod J 46:1140–1152

    Article  PubMed  Google Scholar 

  16. Bechara B, McMahan CA, Noujeim M, Faddoul T, Moore WS, Teixeira FB, Geha H (2013) Comparison of cone beam CT scans with enhanced photostimulated phosphor plate images in the detection of root fracture of endodontically treated teeth. Dentomaxillofac Radiol 42:20120404

    Article  PubMed  PubMed Central  Google Scholar 

  17. Junqueira RB, Verner FS, Campos CN, Devito KL, do Carmo AM (2013) Detection of vertical root fractures in the presence of intracanal metallic post: a comparison between periapical radiography and cone-beam computed tomography. J Endod 39:1620–1624

    Article  PubMed  Google Scholar 

  18. Byakova SF, Novozhilova NE, Makeeva IM, Grachev VI, Kasatkina IV (2019) The accuracy of CBCT for the detection and diagnosis of vertical root fractures in vivo. Int Endod J 52:1255–1263

    Article  PubMed  Google Scholar 

  19. Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR (2009) Detection of vertical root fractures in endodontically treated teeth by a cone beam computed tomography scan. J Endod 35:719–722

    Article  PubMed  Google Scholar 

  20. Hannig C, Dullin C, Hulsmann M, Heidrich G (2005) Three-dimensional, non-destructive visualization of vertical root fractures using flat panel volume detector computer tomography: an ex vivo in vitro case report. Int Endod J 38:904–913

    Article  PubMed  Google Scholar 

  21. Huang CC, Chang YC, Chuang MC, Lin HJ, Tsai YL, Chang SH, Chen JC, Jeng JH (2014) Analysis of the width of vertical root fracture in endodontically treated teeth by 2 micro-computed tomography systems. J Endod 40:698–702

    Article  PubMed  Google Scholar 

  22. Mora MA, Mol A, Tyndall DA, Rivera EM (2007) In vitro assessment of local computed tomography for the detection of longitudinal tooth fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103:825–829

    Article  PubMed  Google Scholar 

  23. Nair MK, Gröndahl H-G, Webber RL, Nair UP, Wallace JA (2003) Effect of iterative restoration on the detection of artificially induced vertical radicular fractures by tuned aperture computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96:118–125

    Article  PubMed  Google Scholar 

  24. Shemesh H, van Soest G, Wu M-K, Wesselink PR (2008) Diagnosis of vertical root fractures with optical coherence tomography. J Endod 34:739–742

    Article  PubMed  Google Scholar 

  25. Quinto ET (1993) Singularities of the X-ray transform and limited data tomography in <inline-equation> <f> <blkbd>R<sup>2</sup></blkbd></f> </inline-equation> and <inline-equation> <f> <blkbd>R<sup>3</sup></blkbd></f> </inline-equation>. SIAM J Math Anal 24:1215–1225

    Article  Google Scholar 

  26. Varshosaz M, Tavakoli MA, Mostafavi M, Baghban AA (2010) Comparison of conventional radiography with cone beam computed tomography for detection of vertical root fractures: an in vitro study. J Oral Sci 52:593–597

    Article  PubMed  Google Scholar 

  27. Mikrogeorgis G, Lyroudia K, Molyvdas I, Nikolaidis N, Pitas I (2004) Digital radiograph registration and subtraction: a useful tool for the evaluation of the progress of chronic apical periodontitis. J Endod 30:513–517

    Article  PubMed  Google Scholar 

  28. Queiroz PM, Nascimento HA, da Paz TD, Anacleto FN, Freitas DQ (2016) Accuracy of digital subtraction radiography in the detection of vertical root fractures. J Endod 42:896–899

    Article  PubMed  Google Scholar 

  29. Mikrogeorgis G, Eirinaki E, Kapralos V, Koutroulis A, Lyroudia K, Pitas I (2018) Diagnosis of vertical root fractures in endodontically treated teeth utilising digital subtraction radiography: a case series report. Aust Endod J 44:286–291

    Article  PubMed  Google Scholar 

  30. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    Article  Google Scholar 

  31. Chavda R, Mannocci F, Andiappan M, Patel S (2014) Comparing the in vivo diagnostic accuracy of digital periapical radiography with cone-beam computed tomography for the detection of vertical root fracture. J Endod 40:1524–1529

    Article  PubMed  Google Scholar 

  32. Patel S, Horner K (2009) The use of cone beam computed tomography in endodontics. Int Endod J 42:755–756

    Article  PubMed  Google Scholar 

  33. Kositbowornchai S, Nuansakul R, Sikram S, Sinahawattana S, Saengmontri S (2001) Root fracture detection: a comparison of direct digital radiography with conventional radiography. Dentomaxillofac Radiol 30:106–109

    Article  PubMed  Google Scholar 

  34. Tsesis I, Kamburoglu K, Katz A, Tamse A, Kaffe I, Kfir A (2008) Comparison of digital with conventional radiography in detection of vertical root fractures in endodontically treated maxillary premolars: an ex vivo study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106:124–128

    Article  PubMed  Google Scholar 

  35. Rud J, Omnell KA (1970) Root fractures due to corrosion diagnostic aspects. Scand J Dent Res 78:397–403

    PubMed  Google Scholar 

  36. Rudolph DJ, White SC (1988) Film-holding instruments for intraoral subtraction radiography. Oral Surg Oral Med Oral Pathol 65:767–772

    Article  PubMed  Google Scholar 

  37. Tyndall DA, Kapa SF, Bagnell CP (1990) Digital subtraction radiography for detecting cortical and cancellous bone changes in the periapical region. J Endod 16:173–178

    Article  PubMed  Google Scholar 

  38. Stephanopoulos G, Mikrogeorgis G, Lyroudia K (2011) Assessment of simulated internal resorption cavities using digital and digital subtraction radiography: a comparative study. Dent Traumatol 27:344–349

    Article  PubMed  Google Scholar 

  39. Ono E, Medici Filho E, Faig Leite H, Tanaka JL, De Moraes ME, De Melo Castilho JC (2011) Evaluation of simulated external root resorptions with digital radiography and digital subtraction radiography. Am J Orthod Dentofac Orthop 139:324–333

    Article  Google Scholar 

  40. Andersen L, Wenzel A (1995) Individual identification by means of conventional bitewing film and subtraction radiography. Forensic Sci Int 72:55–64

    Article  PubMed  Google Scholar 

  41. Brady E, Mannocci F, Brown J, Wilson R, Patel S (2014) A comparison of cone beam computed tomography and periapical radiography for the detection of vertical root fractures in nonendodontically treated teeth. Int Endod J 47:735–746

    Article  PubMed  Google Scholar 

  42. Wanderley VA, Freitas DQ, Haiter-Neto F, Oliveira ML (2018) Influence of tooth orientation on the detection of vertical root fracture in cone-beam computed tomography. J Endod 44:1168–1172

    Article  PubMed  Google Scholar 

  43. Johari M, Esmaeili F, Andalib A, Garjani S, Saberkari H (2017) Detection of vertical root fractures in intact and endodontically treated premolar teeth by designing a probabilistic neural network: an ex vivo study. Dentomaxillofac Radiol 46:20160107

    Article  PubMed  PubMed Central  Google Scholar 

  44. Farias Gomes A, Nejaim Y, Fontenele RC, Haiter-Neto F, Freitas DQ (2019) Influence of the incorporation of a lead foil to intraoral digital receptors on the image quality and root fracture diagnosis. Dentomaxillofac Radiol 48:20180369.

  45. Queiroz PM, Santaella GM, Capelozza ALA, Rosalen PL, Freitas DQ, Haiter-Neto F (2018) Zoom reconstruction tool: evaluation of image quality and influence on the diagnosis of root fracture. J Endod 44:621–625

    Article  PubMed  Google Scholar 

  46. Nascimento HA, Visconti MA, Ferreira LM, Suarez MA, Haiter Neto F, Freitas DQ (2016) Effect of delayed scanning on imaging and on the diagnostic accuracy of vertical root fractures in two photostimulable phosphor plates digital systems. Int Endod J 49:973–979

    Article  PubMed  Google Scholar 

  47. Patel S, Dawood A, Ford TP, Whaites E (2007) The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J 40:818–830

    Article  PubMed  Google Scholar 

  48. Guo XL, Li G, Yin S, Ma RH, Guo YJ, Bornstein MM (2019) Effect of fracture orientation on detection accuracy of vertical root fractures in non-endodontically treated teeth using cone beam computed tomography. Clin Oral Investig 23:4433–4439. https://doi.org/10.1007/s00784-019-02905-0

    Article  PubMed  Google Scholar 

  49. Abdinian M, Razavian H, Jenabi N (2016) In vitro comparison of cone beam computed tomography with digital periapical radiography for detection of vertical root fracture in posterior teeth. J Dent (Shiraz, Iran) 17:84–90

    Google Scholar 

  50. Guo XL, Li G, Zheng JQ, Ma RH, Liu FC, Yuan FS, Lyu PJ, Guo YJ, Yin S (2019) Accuracy of detecting vertical root fractures in non-root filled teeth using cone beam computed tomography: effect of voxel size and fracture width. Int Endod J 52:887–898

    Article  PubMed  Google Scholar 

  51. Pinto MGO, Rabelo KA, Sousa Melo SL, Campos PSF, Oliveira L, Bento PM, Melo DP (2017) Influence of exposure parameters on the detection of simulated root fractures in the presence of various intracanal materials. Int Endod J 50:586–594

    Article  PubMed  Google Scholar 

  52. Moura MS, Guedes OA, De Alencar AH, Azevedo BC, Estrela C (2009) Influence of length of root canal obturation on apical periodontitis detected by periapical radiography and cone beam computed tomography. J Endod 35:805–809

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The experimental procedures were performed at the Department of Endodontology and Department of Basic Dental Sciences, Division of Dental Tissues Pathology and Therapeutics, School of Dentistry, Faculty of Health Sciences at Aristotle University of Thessaloniki, Greece. The authors would like to express their appreciation to mathematician Konstantinos Bousios for his constructive comments and contribution to statistical analysis.

Author information

Authors and Affiliations

  1. Department of Endodontology, School of Dentistry, Faculty of Health Sciences, Aristotle University of Thessaloniki, Dentistry Building, Aristotle University of Thessaloniki Campus, 54124, Thessaloniki, Greece

    Vasileios Kapralos, Andreas Koutroulis, Eleni Irinakis, Kleoniki Lyroudia & Georgios Mikrogeorgis

  2. Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Pantelis Kouros

  3. Artificial Intelligence and Information Analysis Laboratory, School of Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Ioannis Pitas

Authors
  1. Vasileios Kapralos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andreas Koutroulis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eleni Irinakis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pantelis Kouros
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kleoniki Lyroudia
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ioannis Pitas
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Georgios Mikrogeorgis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vasileios Kapralos.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. The ethical committee of School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece approved the use of human teeth for the research (protocol number 04/14-11-2017).

Informed consent

For this type of study, formal consent is not required.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kapralos, V., Koutroulis, A., Irinakis, E. et al. Digital subtraction radiography in detection of vertical root fractures: accuracy evaluation for root canal filling, fracture orientation and width variables. An ex-vivo study. Clin Oral Invest 24, 3671–3681 (2020). https://doi.org/10.1007/s00784-020-03245-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00784-020-03245-0

Keywords

Search

Navigation