Abst ract
Submitted: July 05, 2016 0RGL¿FDWLRQ6HSWHPEHU Accepted: October 24, 2016
Diagnosis of alveolar and root fract ures:
an
in vit ro st udy com paring CBCT
im aging wit h periapical radiographs
Ob j ect iv e: To com p ar e p er iap ical r ad iog r ap h ( PR) an d con e- b eam com put ed t om ography ( CBCT) in t he diagnosis of alveolar and root fract ures. Mat erial and Met hods: Sixt y incisor t eet h ( 20 higid and 40 wit h root fract ure) from dogs w ere insert ed in 60 ant erior alveolar socket s ( 40 higid and 20 w it h alveolar fract ur e) of 15 m acerat ed canine m axillae. Each fract ur ed socket had a root fract ured t oot h insert ed in it . Aft erwards, each m axilla was subm it t ed t o PR in t w o different vert ical angulat ion incidences, and t o CBCT
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w ere random ized and post eriorly analyzed by t w o oral and m axillofacial radiologist s t w o t im es, w it h a t w o- w eek int er val bet w een obser vat ions.
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PR and CBCT. For alveolar fract ures, sensit ivit y ranged from 0.10 t o 0.90 for
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lower result s t han for root fract ures for PR and CBCT. Areas under t he ROC curve showed good result s for bot h PR and CBCT for root fract ures. However, result s were fair for bot h PR and CBCT for alveolar fract ures. When subm it t ed
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difference bet ween PR and CBCT for root fract ures. Root fract ure int raobserver agreem ent ranged from 0.90 t o 0.93, and alveolar fract ure int raobserver agreem ent ranged from 0.30 t o 0.57. I nt erobserver agreem ent result s w ere subst ant ial for root fract ures and poor/ fair for alveolar fract ures ( 0.11 for PR and 0.30 for CBCT) . Conclusion: Periapical radiograph w it h t w o different vert ical angulat ions m ay be considered an accurat e m et hod t o det ect root fract ures. How ever, PR show ed poorer result s t han CBCT for t he diagnosis of alveolar fract ures. When no fract ures are diagnosed in PR and t he pat ient describes pain sym pt om s, t he subsequent exam of choice is CBCT.
Ke y w or d s: Diagnost ic im aging. Cone- beam com put ed t om ography. Digit al dent al radiography. Toot h fract ures. Bone fract ures.
Solange KOBAYASHI-VELASCO1
Fernanda Cristina Sales SALINEIRO1
Ivan Onone GIALAIN1
Marcelo Gusmão
Paraiso CAVALCANTI1
http://dx.doi.org/10.1590/1678-77572016-0332
1Universidade de São Paulo, Faculdade de Odontologia, Departamento de Estomatologia, São Paulo,
SP, Brasil.
t oot h ( crow n and root ) and adj acent alveolar bone.
While analyzing t he im ages, it is essent ial t o locat e
t he r oot r egion ( cer v ical, m edium or apical t hir d) ,
t he r oot fract ur e line dir ect ion ( hor izont al, oblique
or vert ical) , t he alveolar fract ure locat ion ( buccal or
palat ine/ lingual) and size of t he osseous fragm ent t o
det erm ine t reat m ent and prognosis at t he affect ed
area12,20,23- 25,30.
Per iap ical r ad iog r ap h s ( PR) ar e an im p or t an t
diagnost ic t ool for general pract it ioner s and dent al
specialist s likew ise. How ever, t his m et hod present s a
t w o- dim ensional im age, not allow ing t he observat ion
of buccal and lingual ( or palat ine) regions and result ing
in superim posit ion of st ruct ures8.
CBCT is an im aging m odalit y t hat enables a t
hree-dim ensional analysis of dent al and bone st ruct ures in
t he oral cavit y. This m et hod perm it s a m ore accurat e
int erpret at ion of dent al and alveolar inj uries, allow ing
t he dent ist t o analyze t he area of int erest t hrough
m ult iplanar reconst ruct ed im ages ( axial, coronal and
sagit t al planes)4.
The pur pose of t his st udy w as t o com par e PR
w it h CBCT im aging for t he diagnosis of alveolar and
horizont al root fract ures by using an in vit ro m odel
( m acerat ed canine m axillae) .
Mat erial and m et hods
Preparat ion of sam ples
Sixt y incisor t eet h from t he canine species (Canis lupus fam iliaris) w ere insert ed in 60 ant erior alveolar
socket s of 15m acerat ed canine m axillae for t his st udy.
The socket s w ere previously inspect ed for absence of
fract ures and t he t eet h w ere inspect ed for absence of
cavit ies, root resorpt ion or fract ures.
The Et hics Com m it t ee for t he Use of Anim als at
Th e sam e op er at or, w h o w as n ot in v olv ed in
int erpret ing t he im ages, induced t he root fract ure in
40 t eet h. Each t oot h was placed on a horizont al soft
foundat ion7,16,27 and a ham m er was used t o apply a
perpendicular force. The fragm ent s w ere glued w it h
cy an oacr y lat e ( Hen k el, São Pau lo, SP, Br azil) as
previously described by Cost a, et al.7( 2011) ( Figure
1A) .
For t he alveolar fract ure, a novel t echnique was
developed. Fir st , t he m ax illae w er e pr epar ed w it h
m odelling wax ( Lysanda, São Paulo, SP, Brazil) around
t h e alv eolar pr ocess. Th is st ep w as im por t an t t o
keep bone fragm ent s in posit ion aft er t he fract ur e
( m im icking t he gum s) during t he im age acquisit ion.
The operat or inser t ed an indiv idualized m et al bolt
( w it h it s diam et er sm aller t han t he alveolar socket
diam et er) inside t he t oot hless socket . Anot her person
m aint ained t he m axilla in posit ion and held buccal
DQGSDODWLQHFRUWLFHVZLWKWKHWKXPEDQGLQGH[¿QJHU 7KH ¿UVW RSHUDWRU DSSOLHG D IRUFH DW WKH EROW KHDG
w it h a ham m er. The bolt t ip produced a pressure at
t he bone r esult ing in t he alveolar fract ur e ( Figur e
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inspect ion. The fract ured t oot h was t hen insert ed in
t he socket .
I m age acquisit ion
The operat or w ho induced t he root fract ure also
acquired all t he periapical radiographs and t he CBCT
im ages. Digit al PRs w er e obt ained by using Focus
( I nst rum ent arium Dent al, Tuusula, Finland) int raoral
X- ray at 7m A, 60 kVp and 0.06 seconds of exposure
t im e, Vist aScan ( Durr Dent al, Biet igheim - Bissingen,
Ger m any ) int raoral phosphor st orage plat es ( PSP)
an d Per ioPlu s ( Du r r Den t al, Biet igh eim - Bissin gen ,
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long axis and t he second one in a 10 degree vert ical
angle variat ion increase t owards t he crow n ( in such
a way t hat t he observers had t w o different im ages
t o analyze) , sim ilarly t o t he t echnique described by
Celikt en, et al.5( 2014) .
CBCT im ages w ere acquired at Planm ecaProMax
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t oot h prot ocol w it h t he follow ing param et ers: 80 kV,
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and 500 fram es. Condensat ion silicone dent al put t y
( Op t osil, Her aeu s- Ku lzer, Han au , Ger m an y ) w as
used t o posit ion t he m axilla t o sim ulat e t he pat ient ’s
posit ioning at t he t om ography.
The aut hors opt ed for com paring PR w it h CBCT
im ages because CBCT is a very w idespread im aging
m odalit y in dent ist ry6.
Radiographic assessm ent
Obser v at ion sequ en ces f or bot h PR an d CBCT
im ages w ere random ized t hrough a w ebsit e (w w w.
random .org, Random ness and I nt egrit y Services Lt d,
Dublin, I reland) . Tw o blind previously calibrat ed and
CBCT t rained oral and m axillofacial radiologist s used
t he sam e w orkst at ion independent ly t o perform t he
analyses. I n order t o assess int raobserver agreem ent ,
all im ages w ere evaluat ed aft er a t w o- w eek int erval.
Periapical im ages w ere observed on an iMac 27”
Mac OS X ( Apple, Cupert ino, USA) w orkst at ion, in 15
random izedgroups. Each group cont ained t wo im ages
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t o t he long axis and t he second one on a 10 degree
v er t ical an g le v ar iat ion t ow ar d s t h e cr ow n ) . Th e
observers had t o ident ify t he root fract ure ( yes/ no) ,
and t he presence of alveolar fract ure ( yes/ no) .
CBCT im ages w er e im por t ed in t o Osir iX 3 . 8 . 1
( Pix m eo, Geneva, Sw it zer land; ht t p: / / w w w. osir
ix-v iew er. com /) , an op en - sou r ce DI COM v iew er f or
MacOS. Observers could use all soft ware feat ures t o
ident ify root fract ure ( yes/ no) and presence of alveolar
f r act u r e ( y es/ n o) . Th e ob ser v er s in t er p r et ed t h e
volum e dat a using m ult iplanar reconst ruct ed im ages
( axial, coronal and sagit t al) sim ult aneously.
Dat a analysis
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a s 0 ( a b sen ce o f f r a ct u r e) a n d 1 ( p r esen ce o f
fract ure) and com pared wit h t he gold st andard ( visual
in spect ion ) . All dat a w er e t abu lat ed an d in ser t ed
int o MedCalc ( MedCalc Soft ware, Ost end, Belgium )
sof t w ar e. Sen sit iv it y, sp ecif icit y an d ar ea u n d er
t h e r eceiv er oper at in g ch ar act er ist ic ( ROC) cu r v e
w ere independent ly calculat ed for each observat ion
perform ed by observers 1 and 2. Subsequent ly, areas
under t he ROC curve were com pared by using repeat ed
m easures ANOVA t est . The sam e rat ionale was used
for t he alveolar fract ures.
St at ist ical analyses w ere perform ed using kappa
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degree of int ra- and int erobserver agreem ent , and
scored as poor agreem ent ( 0- 0.19) , fair agreem ent
( 0 . 2 0 - 0 . 3 9 ) , m o d er a t e a g r eem en t ( 0 . 4 0 - 0 . 5 9 ) ,
subst ant ial agreem ent ( 0.60- 0.79) and alm ost perfect
agreem ent ( 0.80- 1.00)19. Kappa dat a w ere analyzed
using t he w ebsit e w w w.lee.dant e.br ( Epidem iology
and St at ist ics Laborat ory, Dant e Pazzanese I nst it ut e
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num bers follow ed t he sam e t rend for root fract ures,
ranging from 0.85 t o 0.95 for PR and from 0.95 t o 1.00
for CBCT. When observing alveolar fract ures, variat ions
w ere sim ilar for bot h PR ( ranging from 0.50 t o 0.55)
and CBCT ( ranging from 0.55 t o 0.78) .
Areas under t he ROC curve ( AUR) show ed good
result s for bot h PR ( ranging from 0.84 t o 0.89) and
CBCT ( ranging fr om 0.89 t o 0.96) w hen analy zing
r o o t f r act u r es. Fo r al v eo l ar f r act u r es, h o w ev er,
result s w ere fair, ranging from 0.50 t o 0.55 for PR
and from 0.55 t o 0.78 for CBCT. AUR values w ere
su bm it t ed t o r epeat ed m easu r es ANOVA t est s, in
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bet w een PR and CBCT, for root and alveolar fract ures
independent ly. The ANOVA t est s result ed in st at ist ically
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fract ures only.
Table 1 show s k appa values for bot h r oot and
a l v e o l a r f r a ct u r e s. Ro o t f r a ct u r e i n t r a o b se r v e r
hence not allow ing a t horough observat ion of buccal
and palat ine/ lingual r egions. Also, t he diagnosis of
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not parallel t o t he fract ure line26. A t hree- dim ensional
im aging m et hod allow s a m ore t horough visualizat ion
because it elim inat es superim posit ion of st ruct ures4.
I n PR, t he observers w ere able t o visualize a root
fract ure but did not det ect an alveolar fract ure ( Figures
2A and 2B) . How ever, bot h root and alveolar fract ures
w ere observed in CBCT im ages. The root fract ure was
dem onst rat ed in coronal and sagit t al planes, and t he
alveolar fract ure was shown in sagit t al and axial planes
( Figures 3A, 3B, 3C) .
Canine species (Canis lupus fam iliaris) has been
u sed in st u dies in den t ist r y1 3 , 1 7 , 2 1an d it s an t er ior
m axilla and dent al anat om y resem ble t he hum an one.
Several st udies, bot h in vit ro and in vivo2,11,16- 18,
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m et hod w hen com pared w it h periapical radiographs
for diagnosis of root fract ure. Bechara, et al.2 ( 2013)
Root Fracture Alveolar fracture
First Observation Second Observation First Observation Second Observation
Se Sp AUR Se Sp AUR Se Sp AUR Se Sp AUR
Observer 1 Periapical 0.83 0.95 0.89 0.85 0.85 0.85 0.1 0.9 0.5 0.85 0.18 0.51 CBCT 0.9 0.95 0.93 0.93 1.00 0.96 0.5 0.73 0.61 0.65 0.9 0.78 Observer 2 Periapical 0.78 0.9 0.84 0.8 0.95 0.88 0.9 0.13 0.51 0.35 0.75 0.55 CBCT 0.83 0.95 0.89 0.85 0.95 0.9 0.5 0.6 0.55 0.5 0.8 0.65
Table 1-6HQVLWLYLW\6H6SHFL¿FLW\6SDQG$UHDXQGHUWKH52&FXUYH$85YDOXHVIRUURRWDQGDOYHRODUIUDFWXUHVIRUERWKREVHUYHUV
Image Observer 1 X Observer 1 Observer 2 X Observer 2 Observer 1 X Observer 2
Root Fracture Alveolar
Fracture
Root Fracture Alveolar
Fracture
Root Fracture Alveolar
Fracture
Periapical 0.93 0.3 0.9 0.57 0.75 0.11
CBCT 0.9 0.45 0.93 0.54 0.74 0.3
com p ar ed p h ot ost im u lat ed p h osp h or p lat e ( PSP)
im ages w it h CBCT for t he det ect ion of root fract ure on
endodont ically t reat ed t eet h. The aut hors concluded
t hat sm all FOV im ages had a higher accuracy and
sensit ivit y w hen com pared w it h PSP im ages. I n our
st udy, for t he CBCT exam , w e used a sm all FOV and a
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et al.26 ( 2015) and Bechara, et al.2 ( 2013) ] , and also
t he largest num ber of fram es t hat t he m achine allowed
>EDVHGRQWKH¿QGLQJVRI&RVWDHWDO9 ( 2014) ] and obt ained slight ly super ior sensit iv it y and accuracy
lev els f or CBCT, w h en com p ar ed w it h p er iap ical
radiographs for t he det ect ion of r oot fract ur e. We
believe t hat t hese values are explained by t he fact t hat
t w o periapical im ages w ere concom it ant ly analyzed,
w hich allow ed t he observers t o bet t er ident ify root
fract ures by providing t w o different x- ray incidences.
This fact enlight ens t he value of analyzing periapical
radiographs in t w o different angulat ions on det ect ing
root fract ures.
I l g u y, et al .1 8 ( 2 0 0 9 ) r ep or t ed a case w h er e
a p a n o r a m i c r a d i o g r a p h a n d a p o st e r o a n t e r i o r
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t raum a pat ient . These im ages showed bilat eral condyle
and a left m andibular incisor r egion fract ur es and
no dent al fract ures. Aft er t he pat ient was subm it t ed
t o a CBCT exam , alveolar fract ure lines and a root
f r act u r e w er e also diagn osed. Th is st u dy sh ow ed
t he im por t ance of CBCT in ident ify ing sm aller size
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Segm ent al displacem ent s of alveolar bone can be
clinically observed1,29 and addit ional im aging exam s
ar e needed t o pr ov ide fur t her infor m at ion such as
f r act u r e locat ion , ex t en sion an d r elat ion sh ip w it h
im port ant anat om ical st ruct ures. A few case report s
described t he diagnosis of alveolar fract ure by using
radiographs3,10ZKLOHVRPHRWKHUFDVHUHSRUWVDI¿UPHG t hat CBCT is an effect ive diagnost ic m et hod for m inor Figure 3-$&%&7FRURQDOLPDJHRIWKHULJKWODWHUDOLQFLVRUVKRZLQJURRWIUDFWXUH¿OOHGDUURZ%&%&7VDJLWWDOLPDJHRIWKHULJKWODWHUDO LQFLVRUGHSLFWLQJURRWIUDFWXUH¿OOHGDUURZDQGDOYHRODUIUDFWXUHRXWOLQHGDUURZ&&%&7D[LDOLPDJHRIWKHULJKWODWHUDOLQFLVRUVKRZLQJ
alveolar fracture (outlined arrow)
as reasonably achievable) principle , by w hich t he
professional w ill adopt CBCT only in cases in w hich
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a cor r ect diagnosis. Accor ding t o Loubele, et al.22
( 2009) , radiat ion dose needs t o be kept as low as
possible, however allowing a good qualit y im age for t he
diagnosis. I n our result s, w e observed a propensit y t o
slight ly higher result s wit h CBCT, when com pared wit h
periapical radiographs. We believe t hat CBCT exam is
necessary in cases in w hich t he periapical radiograph
does not show a fract ure line but t he pat ient show s
sym pt om s t hat could be associat ed w it h root and/ or
alveolar fract ure. Hence, t he clinician has t o balance it s
KDUPIXOQHVVZLWKLWVHI¿FLHQF\WRSUHVFULEHWKLVH[DP6. According t o Yam am ot o, et al.28 m ore st udies are
needed t o analyze t he long- t erm clinical im plicat ions of
alveolar fract ure such as locat ion, severit y, and st age
of child developm ent when t he fract ure occurred. Thus,
a correct im aging diagnosis is essent ial for a bet t er
prognosis and t reat m ent out com e.
Conclusions
Periapical radiographs w it h t w o different vert ical
angulat ions m ay be considered an accurat e m et hod
t o det ect root fract ures. How ever, PR show ed low er
result s for t he diagnosis of alveolar fract ures w hen
com par ed w it h CBCT im aging. When no fract ur es
are diagnosed in PR and t he pat ient describes pain
sym pt om s, t he subsequent exam of choice is CBCT.
Acknow ledgem ent s
Funding was provided by CNPq – Nat ional Council
for 6FLHQWL¿FDQG7HFKQRORJLFDO'HYHORSPHQW, Brasília, Brazil, grant no. 303847/ 2009- 3 ( t o MGPC) ; Universal
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