Clinical Oral Investigations

, Volume 23, Issue 3, pp 1263–1270 | Cite as

Diagnosis of vertical root fracture in teeth close and distant to implant: an in vitro study to assess the influence of artifacts produced in cone beam computed tomography

  • Deborah Queiroz FreitasEmail author
  • Taruska Ventorini Vasconcelos
  • Marcel Noujeim
Original Article



To evaluate the influence of artifacts produced by zirconium implant on the diagnosis of vertical root fracture (VRF) in teeth close and distant to the implant in cone beam computed tomography (CBCT) images. We also determined if kilovoltage (kVp) and metal artifact reduction (MAR) tool could influence this diagnosis.

Materials and methods

Twenty single-root teeth were divided in control and fractured groups (n = 10). The teeth were randomly positioned in the first and second and right and left pre-molar alveoli of a dry human mandible. CBCT exams were acquired using a ProMax 3D unit with varying kVp (70, 80, or 90 kVp), with or without MAR, and with and without a zirconium implant placed in the alveolus of first right molar. The images were evaluated by five observers. The area under the receiver operating characteristic curve (ROC), sensitivity, and specificity were calculated and compared by analysis of variance with a significance level of 5%.


In general, ROC and sensitivity were not affected by the factors studied (p > 0.05). The main effects occurred in specificity; when implant was used without MAR, the values were lower for tooth 45 for all kVps (p = 0.0001).


Artifacts produced in the vicinity of teeth with suspected VRF impair the diagnosis by decreasing the specificity, because they can mimic the VRF line generating false positives. However, MAR improves the specificity, being its use recommended when metallic objects are present near teeth with suspected VRF.

Clinical Relevance

Since nowadays, many patients who undergo CBCT show implants and they definitively produce artifacts, it is important to evaluate the influence of such artifacts in the diagnosis of teeth that are close to the generator-artifact object.


Vertical root fracture Cone beam computed tomography Artifact Kilovoltage Artifact reduction tool 



The authors would like to thank the evaluators.


The work was supported by CAPES (Coordenação do Aperfeiçoamento de Pessoal de Nível Superior—Brazil, process number 88881.118874/2016–01) and the Division of Oral and Maxillofacial Radiology, University of Texas Health Science Center at San Antonio, USA.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Research Ethics Committee of the Piracicaba Dental School, UNICAMP (#2.163.038) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

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


  1. 1.
    Ferreira LM, Visconti MA, Nascimento HA, Dallemolle RR, Ambrosano GM, Freitas DQ (2015) Influence of CBCT enhancement filters on diagnosis of vertical root fractures: a simulation study in endodontically treated teeth with and without intracanal posts. Dentomaxillofac Radiol 44(5):20140352. CrossRefGoogle Scholar
  2. 2.
    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(12):1140–1152. CrossRefGoogle Scholar
  3. 3.
    Nascimento HA, Ramos AC, Neves FS, de-Azevedo-Vaz SL, Freitas DQ (2015) The “Sharpen” filter improves the radiographic detection of vertical root fractures. Int Endod J 48(9):864–871. CrossRefGoogle Scholar
  4. 4.
    Long H, Zhou Y, Ye N, Liao L, Jian F, Wang Y, Lai W (2014) Diagnostic accuracy of CBCT for tooth fractures: a meta-analysis. J Dent 42(3):240–248. CrossRefGoogle Scholar
  5. 5.
    Edlund M, Nair MK, Nair UP (2011) Detection of vertical root fractures by using cone-beam computed tomography: a clinical study. J Endod 37(6):768–772. CrossRefGoogle Scholar
  6. 6.
    Metska ME, Aartman IH, Wesselink PR, Ozok AR (2012) Detection of vertical root fractures in vivo in endodontically treated teeth by cone-beam computed tomography scans. J Endod 38(10):1344–1347. CrossRefGoogle Scholar
  7. 7.
    Bechara B, Alex McMahan C, Moore WS, Noujeim M, Teixeira FB, Geha H (2013) Cone beam CT scans with and without artefact reduction in root fracture detection of endodontically treated teeth. Dentomaxillofac Radiol 42(5):20120245. CrossRefGoogle Scholar
  8. 8.
    Neves FS, Freitas DQ, Campos PS, Ekestubbe A, Lofthag-Hansen S (2014) Evaluation of cone-beam computed tomography in the diagnosis of vertical root fractures: the influence of imaging modes and root canal materials. J Endod 40(10):1530–1536. CrossRefGoogle Scholar
  9. 9.
    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(8):735–746. CrossRefGoogle Scholar
  10. 10.
    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(6):20140428. CrossRefGoogle Scholar
  11. 11.
    Gaêta-Araujo H, Silva de Souza GQ, Freitas DQ, de Oliveira-Santos C (2017) Optimization of tube current in cone-beam computed tomography for the detection of vertical root fractures with different intracanal materials. J Endod 43(10):1668–1673. CrossRefGoogle Scholar
  12. 12.
    Pinto MGO, Rabelo KA, Sousa Melo SL, Campos PSF, Oliveira LSAF, 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(6):586–594. CrossRefGoogle Scholar
  13. 13.
    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(4):621–625. CrossRefGoogle Scholar
  14. 14.
    Schulze RK, Berndt D, d’Hoedt B (2010) On cone-beam computed tomography artifacts induced by titanium implants. Clin Oral Implants Res 21(1):100–107. CrossRefGoogle Scholar
  15. 15.
    Pauwels R, Stamatakis H, Bosmans H, Bogaerts R, Jacobs R, Horner K, Tsiklakis K, SEDENTEXCT Project Consortium (2013) Quantification of metal artifacts on cone beam computed tomography images. Clin Oral Implants Res 24(Suppl A100):94–99. CrossRefGoogle Scholar
  16. 16.
    Pauwels R, Araki K, Siewerdsen JH, Thongvigitmanee SS (2015) Technical aspects of dental CBCT: state of the art. Dentomaxillofac Radiol 44(1):20140224. CrossRefGoogle Scholar
  17. 17.
    Sancho-Puchades M, Hämmerle CH, Benic GI (2015) In vitro assessment of artifacts induced by titanium, titanium-zirconium and zirconium dioxide implants in cone-beam computed tomography. Clin Oral Implants Res 26(10):1222–1228. CrossRefGoogle Scholar
  18. 18.
    Smeets R, Schöllchen M, Gauer T, Aarabi G, Assaf AT, Rendenbach C, Beck-Broichsitter B, Semmusch J, Sedlacik J, Heiland M, Fiehler J, Siemonsen S (2017) Artefacts in multimodal imaging of titanium, zirconium and binary titanium-zirconium alloy dental implants: an in vitro study. Dentomaxillofac Radiol 46(2):20160267. CrossRefGoogle Scholar
  19. 19.
    Vasconcelos TV, Bechara BB, McMahan CA, Freitas DQ, Noujeim M (2017) Evaluation of artifacts generated by zirconium implants in cone-beam computed tomography images. Oral Surg Oral Med Oral Pathol Oral Radiol 123(2):265–272. CrossRefGoogle Scholar
  20. 20.
    Fontenele RC, Nascimento EH, Vasconcelos TV, Noujeim M, Freitas DQ (2018) Magnitude of cone beam CT image artifacts related to zirconium and titanium implants: impact on image quality. Dentomaxillofac Radiol 10:20180021. CrossRefGoogle Scholar
  21. 21.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174CrossRefGoogle Scholar
  22. 22.
    Yoshino K, Ito K, Kuroda M, Sugihara N (2015) Prevalence of vertical root fracture as the reason for tooth extraction in dental clinics. Clin Oral Investig 19(6):1405–1409. CrossRefGoogle Scholar
  23. 23.
    SEDENTEXCT Project (2012) Radiation protection: cone beam CT for dental and maxillofacial radiology. Evidence based guidelines. European Commission, Geneva http://www.sedentexcteu/guidelines. Acessed 12 March 2018 Google Scholar
  24. 24.
    Ma RH, Ge ZP, Li G (2016) Detection accuracy of root fractures in cone-beam computed tomography images: a systematic review and meta-analysis. Int Endod J 49(7):646–654. CrossRefGoogle Scholar
  25. 25.
    Kobayashi-Velasco S, Salineiro FCS, Gialain IO, Cavalcanti MGP (2017) Diagnosis of alveolar and root fractures in macerated canine maxillae: a comparison between two different CBCT protocols. Dentomaxillofac Radiol 46(6):20170037. CrossRefGoogle Scholar
  26. 26.
    Uzun I, Gunduz K, Celenk P, Avsever H, Orhan K, Canitezer G, Ozmen B, Cicek E, Egrioglu E (2015) Comparing the effect of different voxel resolutions for assessment of vertical root fracture of permanent teeth. Iran J Radiol 12(3):e18290. Google Scholar
  27. 27.
    Bragatto FP, Iwaki Filho L, Kasuya AV, Chicarelli M, Queiroz AF, Takeshita WM, Iwaki LC (2016) Accuracy in the diagnosis of vertical root fractures, external root resorptions, and root perforations using cone-beam computed tomography with different voxel sizes of acquisition. J Conserv Dent 19(6):573–577CrossRefGoogle Scholar
  28. 28.
    Queiroz PM, Groppo FC, Oliveira ML, Haiter-Neto F, Freitas DQ (2017) Evaluation of the efficacy of a metal artifact reduction algorithm in different cone beam computed tomography scanning parameters. Oral Surg Oral Med Oral Pathol Oral Radiol 123(6):729–734. CrossRefGoogle Scholar
  29. 29.
    Queiroz PM, Santaella GM, da Paz TD, Freitas DQ (2017) Evaluation of a metal artefact reduction tool on different positions of a metal object in the FOV. Dentomaxillofac Radiol 46(3):20160366. CrossRefGoogle Scholar
  30. 30.
    Kamburoglu K, Kolsuz E, Murat S, Eren H, Yüksel S, Paksoy CS (2013) Assessment of buccal marginal alveolar peri-implant and periodontal defects using a cone beam CT system with and without the application of metal artefact reduction mode. Dentomaxillofac Radiol 42(8):20130176. CrossRefGoogle Scholar
  31. 31.
    de-Azevedo-Vaz SL, Peyneau PD, Ramirez-Sotelo LR, Vasconcelos Kde F, Campos PS, Haiter-Neto F (2016) Efficacy of a cone beam computed tomography metal artifact reduction algorithm for the detection of peri-implant fenestrations and dehiscences. Oral Surg Oral Med Oral Pathol Oral Radiol 121(5):550–556. CrossRefGoogle Scholar
  32. 32.
    Oliveira ML, Freitas DQ, Ambrosano GM, Haiter-Neto F (2014) Influence of exposure factors on the variability of CBCT voxel values: a phantom study. Dentomaxillofac Radiol 43(6):20140128. CrossRefGoogle Scholar
  33. 33.
    Pauwels R, Silkosessak O, Jacobs R, Bogaerts R, Bosmans H, Panmekiate S (2014) A pragmatic approach to determine the optimal kVp in cone beam CT: balancing contrast-to-noise ratio and radiation dose. Dentomaxillofac Radiol 43(5):20140059. CrossRefGoogle Scholar
  34. 34.
    Demirturk Kocasarac H, Helvacioglu Yigit D, Bechara B, Sinanoglu A, Noujeim M (2016) Contrast-to-noise ratio with different settings in a CBCT machine in presence of different root-end filling materials: an in vitro study. Dentomaxillofac Radiol 45(5):20160012. CrossRefGoogle Scholar
  35. 35.
    Helvacioglu-Yigit D, Demirturk Kocasarac H, Bechara B, Noujeim M (2016) Evaluation and reduction of artifacts generated by 4 different root-end filling materials by using multiple cone-beam computed tomography imaging settings. J Endod 42(2):307–314. CrossRefGoogle Scholar
  36. 36.
    Pinheiro LR, Scarfe WC, de Oliveira Sales MA, Gaia BF, Cortes AR, Gusmão Paraiso Cavalcanti M (2017) Effectiveness of periapical radiography versus cone beam computed tomography with different kilovoltage settings in the detection of chemically created peri-implant bone defects: an in vitro study. Int J Oral Maxillofac Implants 32(4):741–750. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental SchoolUniversity of CampinasPiracicabaBrazil
  2. 2.Division of Oral Radiology, School of DentistryFederal University of BahiaSalvadorBrazil
  3. 3.Department of Comprehensive Dentistry, Division of Oral and Maxillofacial RadiologyUniversity of Texas Health Science Center at San AntonioSan AntonioUSA

Personalised recommendations