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Title The Use of Artifact Reduction Software on CBCT with Beam Hardening May Reduce Vertical Root Fractures Detection Chances
Clinical Question For the detection of vertical root fractures on CBCTs with beam hardening artifacts, will enhanced image artifact reduction software as compared to no modification, be more effective in detecting the fractures?
Clinical Bottom Line For patients receiving CBCT for a tooth with a suspected vertical root fracture, the use of metallic artifact reduction software is not suggested as it reduces the chances of accurate detection of the fracture.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 34003491Fontenele/20218 laboratory studies, 515 single rooted teethSystematic Review with Meta-analysis
Key resultsThe evidence quality projected low confidence in outcomes estimation. Values with and without metal artifact reduction software were 0.586 and 0.603 for sensitivity, 0.699 and 0.713 for specificity, 0.699 and 0.713 for diagnostic odds ratio, and 0.67 and 0.71 for area under the curve for vertical root fracture diagnosis.
#2) 33828962Oliveira/202145 extracted premolars subdivided into 3 groups: 1-metal post 2-Gutta Percha 3-No FillLaboratory study
Key resultsThe area under the curve was lesser overall when using the metal artifact reduction (MAR) software (0.695 compared to 0.789). It appears that the MAR (metal artifact reduction) tool had a negative impact on the overall diagnosis of VRFs (vertical root fractures) in the tested subgroups. The performance metrics for diagnosis, including accuracy, sensitivity, and specificity, were lower when using the MAR tool compared to when not using it. The findings for the two scenarios are: With MAR Tool: Accuracy: 0.45-0.72, Sensitivity: 0.6-0.67, Specificity: 0.23-0.8 Without MAR tool: Accuracy: 0.68-0.77, Sensitivity: 0.67-0.83, Specificity: 0.53-0.87 Taking into consideration P<0.05: for metal post subdivision, there were significant statistical differences; however, in the other two subdivisions the difference was not significant.
Evidence Search ("Cone-Beam Computed Tomography"[Mesh]) and (“Metal artifact reduction tool” [Mesh]) and (“Vertical root fracture” [Mesh])
Comments on
The Evidence
Fontenele's systematic review and meta-analysis offers a comprehensive examination of the existing literature. They conducted both the statistical analysis and outlined the eligibility criteria in a meticulous manner within their published paper. Moreover, they assessed the risk of bias using the Quality Assessment Tool for Diagnostic of Accuracy Studies-2 (QUADAS-2) and determined the confidence level using the GRADEpro software. Nevertheless, this study does have some weaknesses. First, the authors themselves acknowledge a low level of evidence and high heterogeneity as a primary weakness. Second, the use of the term "teeth with intracanal materials" lacks precision, as not all intracanal materials possess "high-density" or "radiopaque" characteristics. This imprecision could be problematic, as the study's purpose might be compromised if the density of the obturation material differs significantly from "metal-density." Additionally, all eight studies included in this analysis focus solely on single-rooted teeth, which may exhibit distinct fracture patterns compared to multi-rooted teeth with various furcation areas. Oliveira's laboratory study, on the other hand, employed artificially induced vertical root fractures, which may not precisely replicate the patterns and definitions found in in vivo fractures. However, the study used a range of metallic densities, including metal and Gutta Percha, and maintained a control group with unfilled teeth. The research adhered to a gold standard when assessing all the premolars, with two different oral and maxillofacial radiologists serving as evaluators. The results exhibited strong consistency across the three sub-groups. Nevertheless, limitations of the study exist, such as reliance on a single cone-beam computed tomography (CBCT) system (and consequently a single metal artifact reduction software), the utilization of artificially generated vertical fractures, and a lack of information regarding interrater reliability.
Applicability In clinical practice, this is important because teeth with vertical root fractures often have metallic crowns and/or root canals, which create beam hardening artifacts that make it difficult to accurately see the root. Thus, in the search for such fractures, a clinician may be tempted to use the artifact reduction tool on the software to improve visualization. As can be seen from these 2 studies, the use of such tools actually makes the clinician less likely to accurately diagnose a root fracture, and therefore should not be used.
Specialty/Discipline (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Periodontics)
Keywords Metal artifact reduction tool, Vertical root fracture, CBCT, fracture detection.
ID# 3549
Date of submission: 10/25/2023spacer
E-mail Cordahi@livemail.uthscsa.edu
Author Joe Cordahi
Co-author(s) Cody Pewarchuk
Co-author(s) e-mail pewarchuk@livemail.uthscsa.edu
Faculty mentor/Co-author Hassem Geha DDS,MDS
Faculty mentor/Co-author e-mail geha@uthscsa.edu
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