Detection of Vertical Root Fractures Using Three Different Imaging Modalities: An In Vitro Study

Abstract

Background:
The diagnosis of nondisplaced longitudinal fractures [vertical root fractures (VRFs)] is challenging in clinical practice. Radiographic techniques showed a difficulty in detection of VRFs. Cone-beam computed tomography (CBCT) is a new diagnostic imaging modality that provides high-quality three-dimensional (3D) images for dental diagnosis.

Aims:
The aim of this in vitro study is to compare accuracy of three different imaging modalities: conventional periapical radiographs, digital radiographs, and CBCT in detecting VRFs in teeth that are endodontically as well as nonendodontically treated.

Materials and methods:
An in vitro model consisting of 60 recently extracted human mandibular lower premolars were used. Root canal treatment was carried out for 30 teeth. Root fractures were created in 30 teeth (15 root canal treated and 15 non-treated) by mechanical force. Other 30 teeth remain intact. The teeth were mounted and images were taken with a periapical, digital, and CBCT X-ray unit. Three endodontists separately evaluated the images.

Results:
Interobserver κ values showed a very good interobserver agreement (0.98 for CBCT, 0.88 for digital, and 0.93 for conventional periapical X-rays). There was an overall statistically significant difference (p = 0.00) in detecting of root fracture among the three imaging modalities and the highest accuracy with CBCT images.

Conclusions:
In in vitro model, CBCT scan appears to give the highest accuracy in detecting VRFs when compared with the periapical systems in both endodontically and nonendodontically treated teeth.

Clinical significance:
The CBCT scan shows higher sensitivity in detection of VRFs in comparison with periapical images.

Full text

ORIGINAL RESEARCH
Detection of Vertical Root Fractures Using Three Different
Imaging Modalities: An In Vitro Study
Dunia Al Hadi1, Sana Parekh2, Warda Naeem3, Alexander M Luke4, Simy Mathew5
Abstr A c t
Background: The diagnosis of nondisplaced longitudinal fractures [vertical root fractures (VRFs)] is challenging in clinical practice. Radiographic
techniques showed a diculty in detection of VRFs. Cone beam computed tomography (CBCT) is a new diagnostic imaging modality that
provides high-quality three-dimensional (3D) images for dental diagnosis.
Aims: The aim of this in vitro study is to compare accuracy of three dierent imaging modalities: conventional periapical radiographs, digital
radiographs, and CBCT in detecting VRFs in teeth that are endodontically as well as non-endodontically treated.
Materials and methods: An in vitro model consisting of 60 recently extracted human mandibular lower premolars were used. Root canal
treatment was carried out for 30 teeth. Root fractures were created in 30 teeth (15 root canal treated and 15 non-treated) by mechanical force.
Other 30 teeth remain intact. The teeth were mounted and images were taken with a periapical, digital, and CBCT X-ray unit. Three endodontists
separately evaluated the images.
Results: Interobserver κ values showed a very good interobserver agreement (0.98 for CBCT, 0.88 for digital, and 0.93 for conventional periapical
X-rays). There was an overall statistically signicant dierence (p = 0.00) in detecting of root fracture among the three imaging modalities and
the highest accuracy with CBCT images.
Conclusions: In in vitro model, CBCT scan appears to give the highest accuracy in detecting VRFs when compared with the periapical systems
in both endodontically and non-endodontically treated teeth.
Clinical signicance: The CBCT scan shows higher sensitivity in detection of VRFs in comparison with periapical images.
Keywords: Cone beam computed tomography, Laboratory research, Root canal treatment, Vertical root fractures.
The Journal of Contemporary Dental Practice (2020): 10.5005/jp-journals-10024-2839
Intro d u c tIon
Vertical root fracture (VRF) is dened as a complete or incomplete
fracture initiated from the root at any level, usually directed
bucco-lingually.1 According to the literature, VRF is the third most
common reason for extraction of an endodontically treated tooth.2
It has been suggested that improper selection of intracanal posts
and cementation techniques or excessive pressure during lateral
condensation of gutta-percha are among the main etiological
factors causing root fractures.3
Testori et al.4 reported that premolars have the highest
incidence of VRF in endodontically treated teeth; however, Chan
et al.5 reported rst molars to be the teeth with higher frequency
of root fractures.
Vertical root fractures are also prevalent in vital teeth (non-
endodontically treated teeth). In vital teeth, VRFs occur due to
factors such as repetitive and heavy masticatory stress referred
to as “fatigue root fractures,”6 strong masticatory forces, habitual
chewing of hard food, and less pliable supporting bone.7
The diagnosis of VRFs is a signicant challenge for the dental
practitioner.3,8 Vertical root fr actures are dicult to diagnose using
conventional and digital radiographic methods, and the line of
fracture could of ten be overlooked if the X-ray beam does not pass
parallel through it.9 Hence, at least two per iapical radiographs, with
dierent angulations, are needed in order to detec t such fractures.
Digital radiography uses sensors instead of traditional
photographic film and special image processing techniques
that enhance overall display of the image and the quality can
be enhanced and zoomed in and out. However, studies have
shown that digital radiography provides equivalent results when
compared with an F-speed conventional radiographic lm in the
detection of VRFs in single-rooted teeth.1 Cone beam computed
tomography (CBCT) is a diagnos tic imaging modality that provides
high-quality, accurate 3D images of the osseous elements of the
maxillofacial skeleton.10
Previous studies have evaluated the accuracy of the CBCT
system compared with digital and periapical radiographs in the
detection of VRFs. While it is agreed that detection of VRFs is a
challenge using two-dimensional (2D) radiographic images, there
is no agreement on the accuracy of CBCT imaging in detecting
VRFs.11,12
1Department of Restorative Dentistry, College of Dentistry, Ajman
University, Ajman, United Arab Emirates
2,3College of Dentistry, Ajman University, Ajman, United Arab Emirates
4Department of Surgical Sciences, College of Dentistry, Ajman
University, Ajman, United Arab Emirates
5Department of Growth and Development, College of Dentistry,
Ajman University, Ajman, United Arab Emirates
Corresponding Author: Alexander M Luke, Department of Surgical
Sciences, College of Dentistry, Ajman University, Ajman, United Arab
Emirates, Phone: +971 555171094, e-mail: alexvinod@gmail.com
How to cite this article: Hadi DA, Parekh S, Naeem W, et al. Detection
of Vertical Root Fractures Using Three Dierent Imaging Modalities: An
In Vitro Study. J Contemp Dent Pract 2020;21(5):549–553.
Source of support: Nil
Conict of interest: None
© The Author(s). 2020 Open Access This article is distributed unde r the terms of the Creative Commons Attributio n 4.0 International License (https: //creativecommons.
org/licenses/by- nc/4.0/), which permits unrestric ted use, distribution, and non -commercial reproduc tion in any medium, provided yo u give appropriate credit to
the original author(s) and the source, prov ide a link to the Creative Commons license, and indicate if ch anges were made. The Creative Commons Pub lic Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Detection of VRFs
The Journal of Contemporary Dental Pracce, Volume 21 Issue 5 (May 2020)
550
The aim of this in vitro study is to compare accuracy of three
dierent imaging modalities: conventional periapical radiographs,
digital radiographs, and CBCT in detecting VRFs in teeth with and
without root canal treatment.
MAterIAl s A nd Metho d s
The Research Ethics Committee of the Faculty of Dentistry (RD-
2014/15-01) approved the present study. In total, 100 extracted
single-rooted lower premolars were collected for the study. The
teeth were cleaned and disinfected and then examined under
stereomicroscope, under the m agnication of 8×. These teeth were
then mounted in wax, and preoperative periapical radiographs
were taken to conrm teeth with single canals and absence of
preexisting fractures, root resorptions, dental anomalies and
conrm that they were not previously endodontically treated. The
sample was placed in normal saline during all stages of the study.
After the preoperative assessment, 60 sound teeth were
selected, and further divided into the following groups.
• Group I consisting of 30 teeth underwent root canal therapy;
• Group II consisting of 30 teeth received no root canal therapy.
Group I teeth were mounted in wax individually, and access
cavities were prepared; the canals were then prepared using
WaveOne reciprocating motor system and primer WaveOne le
and obturated with the cold lateral compaction technique. Later,
all teeth were decoronated to continue the experiment.
Group I was then subdivided into
Group I1: 15 teeth subjected to mechanical force using a
hammer and nail to create a crack (nondisplaced VRF).
Group I2: 15 teeth not subjected to any mechanical force (no
root fracture).
Group II subdivided into
Group II1: 15 teeth subjected to mechanical force using
the Instron Universal Testing Machine to create a vertical crack
(nondisplaced VRF).
Group II2: 15 intact teeth.
Teeth were reexamined under the stereomicroscope, under
the magnification of 8× to detect the presence of the cracks
(nondisplaced VRF) (Fig. 1).
Before radiographic examination, all teeth were mounted in
wax and covered with putty material, so that it can replicate soft
tissue and bone.
Imaging Techniques
All teeth were then subjected to the three different imaging
modalities: conventional periapical, digital, and CBCT.
Cone beam computed tomography images were obtained
using Carestream® CS 9000 3D CBCT using the following exposure
factors: 60 kVp, 5 mA, and 10 ms. Scans of the sample made with
3.7 × 5 cm eld of view selection and 76 × 76 × 76 μm (isotropic
voxel) was used (Fig. 1).
Images were analyzed through the Digital Imaging Software
CS 3.7.5 for CBCT machine.
Digital intraoral radiograph was taken using Carestream 6200
at two dierent horizontal angles (0° and 15° mesial) using the
following exposure factors: 60 kVp, 7 mA, and 0.20 seconds. Images
were analyzed with Digital Imaging Software CS 3.7.5 for CBCT
machine. Periapical images were taken using Carestream 2200 at two
dierent horizontal angles (0° and 15° mesial) using the following
exposure factors: 60 kVp, 7 mA, and 0.20 seconds. Periapical lms
were then processed in a standard pattern of developing, washing,
xing, and rewashing. The solutions were changed after every 10
periapical lms were exposed.
Image Assessment
The images obtained were evaluated by three observers, two of
whom were endodontists with more than 5 years of experience
in clinical practice and one was a general dental practitioner. The
criteria decided for the detection of VRFs was direct visualization
of a radiolucent line on the root sur face. The fracture/non-fracture
assessment was recorded as a binary score: 1 if a fracture was
present or 0 if it was not. The decisions of the observers were not
inuenced by any of the researchers. The images were displayed
and analyzed on a computer monitor. Adjustment of contrast and
brightness been applie d, if considered necessary, using the inbuilt
image processing tools.
Statistical Analysis
Data analysis was per formed using IBM SPSS Version 20. κ statistics
was used to determine the interobserver reliability. Chi-square
statistics was used to determ ine the dierences in accuracy among
the three imaging modalities. Results were considered signicant
at p lower than 0.05. Sensitivity and specicity for each imaging
technique were calculated.
• Fracture/non-fracture scores were evaluated as follows:
correct identification of a non-fractured root was considered
as true negative (TN), correct identification of fracture
site in a fractured root was identified as true positive (TP),
identification of a fracture in a non-fractured root was
identified as false-positive (FP), incorrect identification of
a fracture site in a fractured root was identified as false-
negative (FN), and failure to identify a fracture in a fractured
root was recorded as FN.
• Sensitivity, specicity, accuracy, positive predictive value, and
negative predictive value among the three imaging modalities
were calculated as follows:
Sensitivity = TP/TP + FN,
Specicity = TN/TN + FP,
Accuracy = TP + TN/TP + TN + FP + FN,
Positive predictive value = TP/TP + FP,
Negative predictive value = TN/TN + FN
Fig. 1: Vertical root fracture detected by cone beam computed
tomography images

Detection of VRFs
The Journal of Contemporary Dental Pracce, Volume 21 Issue 5 (May 2020) 551
results
The frequencies of VRF in each type of radiograph for non-
obturated and obturated teeth are described in Tables 1 and 2.
The sensitivity a nd specicity, respectively, of the VRF diagnosis
in the assessment of non-obturated canals using:
• Periapical radiographs could not be determined as they were
all identied as non-fractured;
• Digital radiographs were 84.4 and 100% (κ = 0.844, p = 0.00);
• CBCT images were 100 and 100% (κ = 1.00, p = 0.000).
The sensitivity a nd specicity, respectively, of the VRF diagnosis
in the assessment of obturated canals using:
• Periapical radiographs were 33.3 and 97.8% (κ = 0 .3 11, p = 0.000);
• Digital radiographs were 86.7 and 84.4% (κ = 0.7 11, p = 0.00);
• Cone beam computed tomograp hy images were 93.3 and 100%
(κ = 0.933, p = 0.000).
The accuracy of the var ious radiographic modalities in detec ting
VRF in non-obturated vs obturated teeth are depicted in Table 3.
The receiver operating characteristic (ROC) curve is important
to assess the accuracy of the various radiographic images in
detection of VRF in both obturated and non-obturated teeth.
When comparing the area under curve in the assessment of the
non-obturated teeth radiographic images, the periapical shows
an area of 0.5 [condence interval (CI): 0.380–0.620, p = 1.0], the
digital radiographic image gives an area of 0.922 (CI: 0.858–0.986,
p = 0.033), and the CBCT imaging an area of 1.000 (p = 0.000) (Fig. 2).
In the assessment of VRF in the radiographs of the obturated
teeth, the periapical radiographs show an area of 0.656 (CI: 0.542–
0.770, p = 0.11), the digital radiographic image gives an area of 0. 856
(CI: 0.771–0.940, p = 0.000), and the CBCT imaging des cribes an area
of 0.967 (CI: 0.924–1.00, p = 0.000) (Fig. 3).
dIscu s s Ion
This study compared three radiographic s ystems, CBCT, digital, and
conventional lm-based periapical radiography, for their accuracy
in detecting experimental root fractures. The statistical analysis
showed that there is a signicant dierence in obtaining images
of the fractured te eth between conventional periapical and digital
or CBCT techniques.
In vitro simulating models are not realistic and hardly r epresent
the clinical situations; however, in in vivo studies, the presence or
absence of a fracture can only be conrmed by extraction of the
tooth in question; which is hard to be consented.
On contrary to studies that have conclude d that CBCT imaging
is not a reliable method to detec t VRFs,13–15 th e present study shows
that CBCT appears to be more accurate than conventional dental
radiography and digital radiography in the detection of these
occurrences. The sensitivity in detecting the VRF in the obturated
and non-obturated teeth is highest in the CBCT images. On
interpreting the ROC cur ves, the CBCT shows accuracy as an almost
Table 1: Frequencies of vertical root fractures as seen in the dierent radiographic images in non-obturated teeth
Periapical Digital CBCT
Fractured Not fractured Total Fractured Not fractured Total Fractured Not fractured Total
Fractured 38 0 38 45 0 45
Not fractured 45 45 90 7 45 52 0 45 45
Total 45 45 90 45 45 90 45 45 90
Table 2: Frequencies of vertical root fractures as seen in the dierent radiographic images in obturated teeth
Periapical Digital CBCT
Fractured Not fractured Total Fractured Not fractured Total Fractured Not fractured Total
Fractured 15 1 16 39 7 46 42 0 42
Not fractured 30 44 74 6 38 44 3 45 48
Total 45 45 90 45 45 90 45 45 90
Table 3: Accuracy of dierent radiographic image modalities in detecting
vertical root fractures in obturated and non-obturated teeth
Non-obturated (%) Obturated (%)
Conventional
periapical — 65.5
Digital 92.2 85.5
CBCT 100 96.6
Fig. 2: Receiver operating characteristic curve of accuracy of dierent
radiographic images in detecting vertical root fractures in non-obturated
canals

Detection of VRFs
The Journal of Contemporary Dental Pracce, Volume 21 Issue 5 (May 2020)
552
perfect test in both obturated and non-obturated teeth, whereas
the conventional periapical radio graph has poor diagnostic ability
in the detection of VRF.
Radiographic images are a 2D representation of a 3D object
while CBCT imaging enables the examiner to view the tooth from
multiple planes at dierent angles an d dierent orientations at very
thin slices and at a very high contrast, which accounts for higher
sensitivity of CBCT in comparison to the periapical radiograph.
In agreement with other studies,16–20 the current study showed
that the conventional radiographic lm has the least sensitivity,
specicity, and accuracy compared to the other modalities (digital
and CBCT) in both ob turated and non-obturated groups. For group
II (non-root canal treated teeth), none of the observers were able
to detect the root fracture with the conventional radiographic
lm (sensitivity = 0). Better values were observed with the digital
images (sensitivity = 86.7%). For the specicit y (the ability to detect
all true negatives) of the imaging modalities, CBCT and digital
images produce similar results in the non -root canal treated groups
(specicity = 100%).
The accuracy of radiographic images and the quality of
the images depends on the proper radiographic angulation,
contrast, density, and sensitivity of the clinician in interpreting the
radiographic ndings.21 If any component of the imaging chain
process is compromised, the resulting image may demonstrate
exposure or geomet ric errors and be suboptimal.22 The higher level
of accuracy in detecting VRF in the digital images when compare d
with conventional lm for both root canal treated and non-root
canal treated groups may be due to better quality images and
the ability of changing density and contrast, which can improve
the quality of the image. Similar ndings were observed in other
studies.7,23,24
Previous studies reported a decrease in the CBCT specicity
when the root canal filling was present because it produces
streaking artifacts that might mimic a fracture line.21,25 In the
current study, the presence of root canal lling did not sign icantly
inuence the specicity of CBCT images in detecting VRFs (100%
for both groups). Similar ndings were observed in a r ecent study.26
This could be explained by improved resolution of the images
produced by the CBCT system used.
Similar to this study, Da Silveira et al.25 and Fisekcioglu et al. 27
reported high specicity, sensitivity, and accuracy of CBCT in
detected VRF in teeth with obturated root canals and non-
obturated sound teeth. They concluded that the image quality is
directly aected by the protocol for achieving the image in the
CBCT examination, esp ecially the voxel size. The 0.2 mm or 0.3 mm
voxel resolution scans were suggested for VRF images.25 Other
in vivo studies supported the current ndings and concluded
that CBCT imaging was eective in detecting VRFs with a high
sensitivity and specificity (100 and 89.5% and 80 and 97.5%,
respectively).11
On the contrary, Hassan et al.9 reported variation among the
dierent CBCT systems in their ability to detect VRFs in an ex vivo
study and reported more accuracy with the axial slices than the
sagittal and coronal views. Similarly, Brady et al.13 questioned the
benet of using CBCT for the detection of incomplete VRFs, as the
eective dose of th e CBCT examinations is signicantly higher than
that of periapical radiography. Patel et al.14 concluded inaccuracy
of CBCT in detecting the presence and absence of simulated VRF
in root-lled teeth. In their recent systematic review, Chang et al.12
could not draw any conclusions regarding diagnostic ability of
CBCT in detecting VRFs.
One reason for variation in results is that CBCT systems vary
in their image quality and performance, especially in highly
demanding diagnostic tasks such as the detection of VRFs. The
superiority of th e system in the detection of VRFs can be at tributed
to the voxel size parameter;26 smaller size results in b etter resolution
and contrast.26 In the current study, Carestream CS 9000 3D CBCT
system at specific exposure parameters was able to produce
high-quality images to detect VRFs. Further in vivo researches are
required to determine patient scanning and other parameter s with
CBCT that could inuence the visibility of the fracture line.
clInIcAl sIgn I f IcAnce
It is important to select diagnostic methods that employ low
radiation, low cost, and readily available at every clinical setting
like the digital radiographic images. If both clinical and the digital
radiographic data were not able to provide adequate information,
CBCT can be indicated as the imaging method to assess the
presence of VRFs.
lIMItAtIon
In the present study, the VRFs were mimicked using e xternal forces.
The situation in the oral environment may be diere nt as the width
of the VRFs in vivo may be less thick than those created in vitro.
Further studies on multi-rooted teeth and in vivo conditions are
warranted to assess reliability of the imaging modalities.
concl usIon
With the limitations of this study, it is concluded that CBCT scans
are a reliable imaging modality to detect VRFs. It appears to give
the highest accuracy in detecting VRFs when compared with the
periapical systems in both endodontically and non-endodontically
treated teeth.
Fig. 3: Receiver operating characteristic curve of accuracy of dierent
radiographic images in detecting vertical root fractures in obturated
canals

Detection of VRFs
The Journal of Contemporary Dental Pracce, Volume 21 Issue 5 (May 2020) 553
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