Dentomaxillofacial Radiology (2020) 49, 20200334

© 2020 The Authors. Published by the British Institute of Radiology

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RESEARCH ARTICLE
Accuracy of three cone-­beam CT devices and two software
systems in the detection of vertical root fractures
1
Aline PF Caetano, 2Thiago O Sousa, 1Mariana R Oliveira, 1Karine Evanglista, 3Juliano M Bueno and
1
Maria AG Silva

Faculty of Dentistry, Federal University of Goiás, Goiânia, Goiás, Brazil; 2Private Practioner, Goiânia, Goiás, Brazil; 3São
1

Leopoldo Mandic, Private Practioner, Goiânia, Goiás, Brazil

Objectives : The aim of this study was to compare the accuracy of vertical root fracture
(VRF) detection using three tomography devices and two software systems in teeth with
different endodontic fillings.
Methods : The sample consisted of 45 premolars divided into 3 groups: No filling (NF, n=15);
Gutta percha (GP, n=15) and Metallic Post (MP, n=15). Cone-­beam computed tomography
(CBCT) images were acquired in Kodak 9000 3D, Orthopantomography 300 (OP300) and
PreXion 3D devices, before and after induced root fractures. Two oral radiologists analyzed
all images using InVivoDental and e-­Vol DX software systems. The analysis was repeated after
15 days in 30% of the sample. Data analysis compared receiver operating characteristic (ROC)
curves, as well the areas under the ROC curves. Accuracy, sensitivity, specificity, positive and
negative predictive value were calculated according to each tomographic device and software.
Intra- and interexaminer reliability were tested using the Kappa coefficient.
Results: The highest accuracy was seen in the image set from the PreXion 3D, using InVivo
(0.96) or e-­Vol DX (0.92) in image analysis. The OP300 device presented a similar performance
of the PreXion 3D in teeth with different endodontic fillings. When using e-­Vol DX, the accu-
racy of Kodak 9000 3D improved from 0.62 to 0.74.
Conclusions: The PreXion 3D device is the most accurate when detecting VRF, with a perfor-
mance similar to the OP300 in endodontic filled teeth. Kodak 9000 3D is indicated for teeth
without fillings, with better accuracy using e-­Vol DX software.
Dentomaxillofacial Radiology (2020) 49, 20200334. doi: 10.1259/dmfr.20200334

Cite this article as: Caetano APF, Sousa TO, Oliveira MR, Evanglista K, Bueno JM,
Silva MAG. Accuracy of three cone-­beam CT devices and two software systems in the detec-
tion of vertical root fractures. Dentomaxillofac Radiol 2020; 49: 20200334.

Keywords: tooth fracture; cone-­beam computed tomography; diagnostic imaging

Introduction

Detection of vertical root fractures (VRF) is a chal- anatomical structures and examiners’ clinical experience
lenge in dentistry routine due to the absence of clinical in image interpretation.1
signs in most cases and the use of two-­dimensional (2D) Cone-­beam computed tomography (CBCT) is
radiographs for diagnostic investigation. Periapical recommended to complement VRF diagnosis when
radiographs are usually the first step in oral radiology 2D exams show uncertainty.2–5 However, the detection
for patients suspected of having VRF. However, this of VRF using CBCT images is influenced by technical
2D exam only offers moderate accuracy in recognizing parameters, such as field of view (FOV), voxel size, milli-
VRF because of the influence of X-­ray beam angula- amperage (mA) and kilovoltage (kV) involved in gener-
tion concerning fracture line, the overlapping of other ating high-­resolution images.2,6 Besides, the production
of artifacts on CBCT images when hyperdense dental
Correspondence to: Maria AG Silva, E-mail: ​mariaagsilva@​gmail.​com materials are present can limit VRF diagnosis accuracy.7
Received 13 July 2020; revised 06 October 2020; accepted 07 October 2020 This limitation is mainly seen when the tooth with a
 Accuracy of three CBCT devices and two software in VRF detection
2 of 8 Caetano et al

suspicion of VRF has undergone endodontic treatment Germany).9,23 The crowns of 15 teeth were removed
with intracanal materials.8–14 For that reason, a false using a diamond disc (Isomet 1000, Buehler Ltd, Bluff,
positive or false negative diagnosis can also occur and IL), leaving a standard root size of 16 mm, measured
impact the clinical decision.9,15 with a digital caliper. Metallic posts were produced
Earlier studies have reported the use of image tools using a chrome-­nickel alloy with the best fit possible
for CBCT exams to reduce artifact production, but inside the root canal walls.
without presenting evidence of accuracy in the diagnosis Root fractures were randomly induced in 45 teeth.
of VRF.2,16–18 A new software, e-­Vol DX (CDT Software, These specimens were placed in 25 mm high polystyrene
Bauru, SP, Brazil), has been used to improve image resin blocks with a 10 mm hole. Periodontal ligament
quality when artifacts are present, by applying specific space was simulated with the addition of silicone fluid.24
filters for endodontic diagnostic purposes.19–21 However, After the fractures had been completed, each root frag-
the accuracy of e-­Vol DX software in different tomog- ment was bonded using cyanoacrylate (Super Bonder,
raphy devices for detecting VRF has not been tested. It Loctite® Henkel, Itapevi, SP, Brazil). A set of five teeth
must be considered that tomography devices can have randomly mixed from the three groups was placed at
different technical parameters for image acquisition, a time in a dry mandible to simulate real conditions in
influencing image quality parameters. the mouth. The mandible was covered with a 3 mm wax
We hypothesized that individual parameters related (Epoxiglass, São Paulo, SP, Brazil) in order to simulate
to the image quality of different tomographic devices soft tissue attenuation, and was used as a phantom.
could also influence image tools for artifact reduction For the best fit adjustment of the teeth in the alveolar
in e-­Vol software for VRF diagnosis. This study aimed bone, sockets were widened using a cylinder bur, when
to compare the accuracy of VRF detection using three necessary.
tomography devices and two software systems, including
the novel e-­Vol DX, in teeth with different endodontic Image acquisition and analysis
fillings. A CBCT acquisition was taken twice for all teeth,
before and after root fracture. All samples were
scanned in three tomography devices: Kodak 9000 3D
Methods and materials (Eastman Kodak Company, Rochester, Nova Iorque,
USA), Orthopantomography 300 (Instrumentarium
The Institutional Review Board previously approved Kavo Kerr, Tuusula, Finland) (OP300) and PreXion
this ex vivo study (number # 3.154.013). 3D (Teracom, San Mateo, CA) using the highest
spatial resolution protocol for each device, as shown
Sample in Table 1. The mandible was placed with its infe-
This sample consisted of 45 teeth extracted for clinical rior border parallel to the horizontal plane and the
purposes. The sample size was calculated based on the mid-­sagittal plane was aligned perpendicularly to the
Hajian-­Tilaki22 report, considering a 0.83 accuracy, horizontal plane. The region of interest was centrally
error limits of 0.1 and CI of 95%. These parameters positioned in the field of view (oriented by the laser
resulted in a sample size of a minimum of 42 teeth. lights and the scout image) to avoid distortion from
The following inclusion criteria were: 1) first or second the scanning position.25 Each tomography device
maxillary or mandibular premolars; 2) single root; 3) performed the image reconstruction, and then the
single root canal; and 4) complete root formation. The DICOM files were exported for image analysis. Two
exclusion criteria were: 1) teeth with restoration or oral radiologists with 5 years’ experience were previ-
morphological anomalies; 2) visible root fractures; and ously calibrated to perform the CBCT analyses, until
3) root canal calcifications or obliteration. The sample intra- and interexaminer concordance indicated an
was divided into three groups of teeth according to intraclass correlation coefficient higher than 0.8.
the endodontic treatment: 1- No filling (NF) group: 15 The CBCT scans were randomly analyzed in two
teeth without root canal intervention; 2- Gutta-­percha steps, in the same room, with appropriate lighting:
(GP) group: 15 teeth with root canal treatment and GP
filling; and, 3- Metallic post (MP) group: 15 teeth with
root canal treatment, filled with GP and an intracanal Table 1 Technical image parameters for each CBCT device
metallic post. Kodak 9000 3D OP300 PreXion 3D
FOV (cm) 5 × 3.7 6×4 5.1 × 5.1
Sample preparation Voxel (mm) 0.076 0.085 0.1
30 teeth were chosen randomly and prepared by the same
kV 70 90 90
operator, using a Mtwo NiTi® rotary system (VDW,
mA 10 10 4
Munich, Germany) up to instrument 40. According
Exposure type Pulsed Pulsed Continuous
to the manufacturer’s instructions, teeth were then
filled using a single-­cone technique with Mtwo GP and Acquisition time 10.8 6.1 37
AH 26 cement (Dentsply DeTrey GmbH, Konstanz, CBCT, cone beam CT; FOV, field of view.

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Figure 1 Sagittalviews of premolar teeth, scanned in different CBCT devices (Kodak 9000 3D, OP 300and PreXion 3D) in different image anal-
ysis software (InVivo and e-­Vol DX) andendodontic filling groups (NF- no filling, GP- gutta-­percha and MP- metallicpost).

1- using InVivo Dental Application (Anatomage, San and compared receiver operating characteristic (ROC)
Jose, CA), installed in a desktop computer, connected curves, as well the area under the ROC curve (AUC) for
to a 24-­inch and 1600 × 1200 pixel resolution monitor; each CBCT device,26 with InVivo and e-­Vol DX image
and 2- using e-­Vol DX software (CDT Software, Bauru, sets according to groups.
SP, Brazil) installed in a computer with a 23-­inch and The diagnostic tests of accuracy, sensitivity, speci-
1920 × 1080 pixel resolution monitor, after a 15 days ficity, positive predictive value and negative predictive
interval from the first evaluation. The raw data were value were calculated according to each CBCT device
used for each software. For the second analysis, the and software. Scores 1, 2 and 3 were considered VRF
examiners had the aid of a Blooming Artifact Reduc- absence, while classifications 4 and 5 were considered
tion (BAR) filter, as one of the e-­Vol DX software VRF presence.
main tools. This feature allowed the examiners to Intra- and interexaminer agreement were tested using
switch between four BAR different levels, preset by κ coefficient,27 considering: (1) poor: values < 0; (2)
the software, according to their visual acuity. During slight: values > 0 and <0.2; (3) fair: values > 0.21 and
all evaluations, the analysis was performed in sagittal, <0.4; (4) moderate: values > 0.41 and <0.6; (5) substan-
coronal and axial views and the examiners were free to tial: values > 0.61 and <0.8 and (6) almost perfect: values
navigate dynamically throughout the CBCT volume. > 0.81 and <1.
The examiners classified the diagnosis of VRF with
the following scores: 1- definitively absent; 2- probably
absent; 3- unsure; 4- probably present; 5- definitively Results
present. Figure 1 shows sagittal views of teeth with
VRF in each group, obtained with the three CBCT Intra- (first examiner 0.71; second examiner 0.77)
devices. 15 days after the first evaluation, the examiners and interexaminer (0.79) reliability in this study was
performed a second analysis of 30% of the sample to substantial.
calculate inter- and intraexaminer agreement. Figure 2 shows the ROCs of three CBCT devices
(Kodak 9000 3D, OP300 and PreXion 3D) and two image
Statistical analysis analysis software systems (InVivo and e-­Vol DX) used in
All data analysis was carried out using MedCalc soft- this study. The highest accuracy seen was the image set
ware 19.0.3 (MedCalc Software, Mariakerke, Belgium). from PreXion 3D, using InVivo or e-­Vol DX in image
The reference standard for VRF was the direct visual analysis. Table 2 shows the accuracy, sensitivity, speci-
inspection of each tooth root. The software created ficity, positive predictive and negative predictive values

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 Accuracy of three CBCT devices and two software in VRF detection
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Figure 2 ROCof three CBCT devices (Kodak 9000 3D, OP 300 and PreXion 3D) and two imageanalysis software (InVivo e e-­Vol DX).

of all CBCT devices and software systems. PreXion 3D InVivo software (p =< 0.001), but the OP300 produced a
presented the highest accuracy (0.96), shown by the results better performance when using e-­Vol DX (0.955; p = 0.05).
of sensitivity (0.94), specificity (0.98), positive predictive The MP group showed the best performance in PreXion
value (0.95) and negative predictive value (0.98), using 3D, but with no statistical difference from the OP300 (p
InVivo software. Image analysis using e-­Vol DX software = 0.9307). The overall AUC comparison of the two soft-
for Kodak 9000 3D images showed higher accuracy (0.74) ware showed similar performances using the same CBCT
and almost all diagnostic tests values compared to the device (Figure 4).
evaluation using InVivo. Sensitivity was the only excep-
tion, higher for InVivo (0.70), compared to e-­Vol DX
(0.63). OP300 showed better sensitivity (0.86) and nega- Discussion
tive predictive value (0.86) using e-­Vol DX, while accuracy
was slightly higher than InVivo. The hypothesis of this study was confirmed. Therefore, the
ROC and AUC comparisons are shown in Figure 3 original imaging parameters of different CBCT devices
and Table 3, respectively. The worst overall ROC perfor- influenced the accuracy in detecting VRF. The e-­Vol DX
mance was obtained with Kodak 9000 3D, while the best software improved almost all diagnostic parameters when
was PreXion 3D. In terms of image analysis of different the images were acquired using Kodak 9000 3D. However,
endodontic fillings, OP300 showed better ROC scores the potential of the BAR filter for removing artifacts and
using e-­Vol DX software when artifacts were present in influencing VRF detection was not confirmed.
the GP group. Each CBCT device’s comparisons showed Our study showed that the PreXion 3D device had the
statistically significant differences between Kodak 9000 best performance, irrespective of the image analysis soft-
3D and OP300 and PreXion 3D devices using InVivo in ware used. However, there was no statistically significant
the NF group, and a similar performance for the other two difference between the OP300 and the PreXion 3D in
groups (GP and MP). The difference was also observed overall accuracy. Although Kodak 9000 3D showed the
between OP300 and PreXion 3D for the GP group. lowest diagnostic values compared to the other devices, its
The OP300 and PreXion 3D presented similar perfor- performance improved when image analysis was under-
mances, differing from Kodak 9000 3D in all groups. taken using e-­Vol DX in NF teeth. However, this progress
This result meant less accuracy for Kodak 9000 3D when did not statistically impact accuracy when compared to
compared to the other devices. For the GP group, all the InVivo software, probably due to the balanced ratio of
devices presented statistically significant differences using sensitivity and specificity changes, which occurred in both

Table 2 Accuracy, sensitivity, specificity, PPV e NPV for each CBCT device and software for VRF detection
Accuracy Sensitivity Specificity PPV NPV
CBCT device InVivo e-­Vol DX InVivo e-­Vol DX InVivo e-­Vol DX InVivo e-­Vol DX InVivo e-­Vol DX
Kodak 9000 3D 0.62 0.74 0.70 0.63 0.54 0.84 0.60 0.80 0.64 0.70
OP300 0.86 0.87 0.82 0.86 0.90 0.88 0.89 0.87 0.83 0.86
PreXion 3D 0.96 0.92 0.98 0.98 0.94 0.86 0.95 0.87 0.98 0.97
CBCT, cone beam CT; NPV, negavtive predcitive value; PPV, positive predcitive value; VRF, vertical root fracture.

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Figure 3 ROCof endodontic filling groups (NF, GP, MP) using InVivo and e-­Vol DX softwaresystems.

software. When using InVivo, the Kodak 9000 3D device False positive values have a direct influence on spec-
showed low specificity, explained by a high number of ificity results. The Kodak 9000 3D device resulted in a
false positive diagnosis of VRF, which means an overdi- 40% false positive VRF and impacted its low specificity
agnosis of VRF when they were, in fact, not present. (0.54) when using InVivo software. In terms of clin-
ical decisions, a false positive diagnosis could result in
Table 3 Area under the Receiver Operating Characteristic Curve clinicians deciding on unnecessary tooth extractions.
(AUC) comparisons of each CBCT device and study groups in InVivo However, when Kodak 9000 3D was analyzed using
and e-­Vol software systems e-­Vol DX, false positive values were reduced to 20%.
CBCT DEVICES (AUC)
PreXion Kodak 9000
GROUPS SOFTWARE 3D OP300 3D p-­value
NF InVivo 0.964A 0907A 0.807B .0117
e-­Vol DX 0.928A 0.872A 0.840A .1016
p-­value 0.14 0.34 0.51

GP InVivo 0.982A 0.875B 0.657C <.0001

e-­Vol DX 0.962A 0.955A 0.674B <.0001
p-­value 0.80 0.05 0.52

MP InVivo 0.949A 0.872A 0.710B .0001

e-­Vol DX 0.921A 0.926A 0.770B .0103
p-­value 0.15 0.26 0.44
AUC, area under the receiver operating characteristic curve; GP,
gutta-­percha; MP, metallic post; NF, no filling.
Delong method comparison between tomography devices and
software (p < .05). Different letters represent statistical significance
between tomography devices and same letters no statistical Figure 4 ROC comparison between InVivo and e-­Vol DX software
significance. systems.

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This notable improvement must be considered by oral of Kodak 9000 3D, compared to OP300 and PreXion 3D,
radiologists when an image scan is performed with taking into account the NF teeth cases.
Kodak 9000 3D. Its association with image analysis It has been reported that the use of filters did not
software that enhances the diagnostic performance can improve the diagnostic accuracy of images acquired with
result in better clinical decision-­making. i-­Cat tomograph.45 Differently, the use of e-­Vol DX in our
Regarding endodontic filling impairing diagnosis, study increased the accuracy for Kodak 9000 3D images,
this study confirmed the result of other studies focusing which had the worst accuracy using InVivo (with no
on VRF detection.10–12,14,28–32 High spatial resolution filter). This finding suggests that depending on the device,
protocols are indicated when there is a suspicion of enhancement tools are a viable alternative for CBCT
VRF in teeth with endodontic fillings. However, these devices. In this way, software companies should focus
high sensitivity values in the detection of VRF in teeth on developing these tools, aiming images acquired with
with root canal fillings must be considered with caution, different devices. Further studies should also be carried
since these results must suggest that streak artifacts to demonstrate e-­Vol DX’s performance in different tech-
could have induced examiners to misdiagnose fracture nical parameters from the same device. For now, it is not
lines overly.30,33 possible to assume if the Prexion 3D or OP 300 should
Considering the three CBCT scanners in this study, be performed better with e-­Vol DX by using different
Kodak 9000 3D had the highest voxel resolution protocol parameters.
(0.076 mm) but showed the worst overall performance, The limitation of this study is related to its ex vivo
reinforcing the other factors' importance that influence study design, which may not represent a similar clinical
image quality. It is known that apart from spatial reso- condition. However, exposing patients to unnecessary
lution, contrast-­to-­noise ratio also affects CBCT image ionizing radiation is unjustified for ethical reasons and
quality.34,35 Contrast-­to-­noise ratio can be enhanced by ex vivo studies are an essential step in answering clinical
adjusting the parameters during acquisition, such as the questions. Another limitation is the sample size. For accu-
field of view scanning size,36 electric current (mAs),33,37 racy values under 0.83, a larger sample should be used to
tube voltage (kVp)38,39 and number of basis images.40 This confirm the study’s power.22 Further studies using other
can explain why Kodak 9000 3D differed from the other technical parameters in association with e-­Vol DX image
devices with higher kilovoltage. Likewise, lower kilo- analysis could contribute to new information.
voltage implies increasing artifact formation,33,38,41 which
also leads to a poorer diagnosis. Although e-­ Vol DX
Conclusion
appears to compensate image quality on images obtained
with a low tube voltage device, further studies are neces-
sary to confirm this hypothesis changing this variable We concluded that the PreXion 3D device is the most
independently in the same device. accurate and presented a similar performance of the
Another essential information from our study is that OP300 for VRF detection in endodontic filled teeth.
images obtained with any of the three tomographs are The Kodak 9000 3D is indicated for VRF detection in
sufficient to detect VRF in teeth with no endodontic filling teeth with no filling and shows improved accuracy when
when associated with the BAR tool. In this way, image using e-­Vol DX software. The e-­Vol DX software did
quality can be balanced with a low radiation dose device, not improve accuracy in images from either OP300 or
mainly because NF teeth are the least challenging scenario PreXion 3D.
amidst the three investigated in this study.
PreXion 3D device’s superior performance can be Acknowledgments
explained by its relatively high radiation dose, obtained
by an increased exposure time and the emission of The authors thank The Dental Radiology Clinics:
continuous radiation. The biologic risk of ionizing radi- Centro Integrado de Radiodontologia; Dental Digital
ation is a factor that must be balanced when CBCT is Imagem and UniEvangelica Radiology Center.
prescribed..42–44 Under the technical parameters of image
acquisition and radiation dose studied by Mauro et al.,42
OP300 represented 531.4 ​ mGy.​ cm² of absorbed dose, Conflict of interest
compared to 2901.6 ​mGy.​cm² for the PreXion 3D, with
the same protocols used in the present study. There is a The authors declare that there is no conflict of interest
5.46:1 ratio between the PreXion 3D and the OP300 in in regard to this work.
absorbed dose. Because the performance of the OP300 in
VRF detection is similar, its use represents a favorable risk/
benefit balance for the patient. On the other hand, adjust- Funding
ments in technical parameters of the PreXion 3D are also
indicated, as the detection of VRF will not be affected This study was partially funded by the Coordination
by a low-­resolution parameter for this device.15 Further for the Improvement of Higher Education Personnel –
studies are still necessary to investigate the radiation dose Brazil (CAPES)

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