Cone beam computed tomography in Endodontics - a review of the literature

The detection of apical radiolucencies in periapical radiographs: A comparison between an artificial intelligence platform and expert endodontists with CBCT serving as the diagnostic benchmark

AIM

Accurate detection of periapical radiolucent lesions (PARLs) is crucial for endodontic diagnosis. While cone beam computed tomography (CBCT) is considered the radiographic gold standard for detecting PARLs in non-root filled teeth, its use is often limited by cost and radiation exposure. Artificial Intelligence (AI)-based radiographic analysis has shown the potential to enhance the diagnostic capability of periapical (PA) radiographs, but its accuracy, compared with CBCT, needs further evaluation. The aim of this paper is to assess the diagnostic accuracy of Diagnocat, a commercial AI-driven platform in detecting PARLs on PA radiographs of teeth diagnosed with irreversible pulpitis or pulp necrosis and scheduled for primary root canal treatment, using CBCT as the reference standard, and to compare Diagnocat's performance with that of experienced clinicians.

METHODOLOGY

This retrospective diagnostic accuracy study analysed 339 teeth (796 roots). PA radiographs were independently assessed by two experienced, calibrated endodontists and by Diagnocat. CBCT scans, serving as the reference standard, were evaluated by two different endodontists, blinded to the PA radiograph results. Sensitivity, specificity, accuracy and area under the receiver-operating characteristic curve (AUC-ROC) were calculated for Diagnocat and clinicians at both tooth and root levels.

RESULTS

CBCT identified PARLs in 121 (35.7%) teeth and 240 (30.2%) roots. Diagnocat displayed a high level of correlation with clinicians in determining lesion status, with an agreement of 89%. Clinicians demonstrated significantly higher accuracy at the tooth level (86.1% vs. 78.5%, p < .001) and greater sensitivity (65.3% vs. 47.9%, p < .001) than Diagnocat, while specificity was comparable (97.7% vs. 95.4%, p = .3). Similar trends were observed at the root level. AUC-ROC values were higher for clinicians than Diagnocat at both tooth (0.81 vs. 0.72) and root (0.77 vs. 0.68) levels, although these differences were not statistically significant.

CONCLUSION

While Diagnocat exhibited high agreement with clinicians in detecting PARLs on PA radiographs, clinicians demonstrated superior accuracy and sensitivity overall. Notably, Diagnocat performed comparably to experienced clinicians in cases without PARLs, highlighting its potential utility for reliably ruling out disease. However, further refinement is required before it can reliably complement clinical judgment in endodontic practice.

Endodontic management of internal replacement resorption of two maxillary central incisors with the aid of cone-beam computed tomography as the diagnostic tool: a case report and review of literature

BACKGROUND

Internal root resorption is an infrequent resorption of dentin and stands among one of the endodontic challenges which comprises two types: internal replacement and inflammatory resorption. Regardless of the location, root resorption does not regress and continues to cause discomfort or sometimes tooth loss if left untreated. Internal replacement resorption is rarer compared with the other type of internal resorption. Regarding the scarcity of internal replacement resorption, the present article reports a case of endodontic management of internal replacement resorption by using NeoPutty mineral trioxide aggregate and cone-beam computed tomography to illustrate and clarify characteristics, diagnosis, possible etiologies, and treatment modalities for internal replacement resorption.

CASE PRESENTATION

A 55-year-old Iranian man was referred for a sinus tract. Periapical radiographs revealed a periradicular lesion and cone-beam computed tomography showed the internal replacement resorption of teeth nos. 8 and 9. The root canal was explored using ultrasonic tips under magnification. Irrigation was done using 2.5% sodium hypochlorite with ultrasonic irrigation. Calcium hydroxide was placed in the root canal for 2 weeks as an intracanal medicament. At the next appointment, after calcium hydroxide removal, the root canal was dried and obturated using NeoPutty mineral trioxide aggregate. At the 2 year follow-up, the teeth were unresponsive to percussion test.

CONCLUSION

Traumatic injuries may lead to internal replacement resorption, which has a progressive nature and urges instant endodontic management. Mineral trioxide aggregate seems to be a promising material for internal replacement resorption. Besides, cone-beam computed tomography and dental operative microscopes can improve the outcome of endodontic therapy in certain challenging cases.

Cone beam computed tomography in dentistry: clinical recommendations and indication-specific features

OBJECTIVES

To provide a narrative overview of commercially available CBCT devices, highlight the wide range of technical features and their impact on image quality and diagnostic performance, and develop decision support charts to guide clinicians in selecting appropriate CBCT parameters for different dental specialties.

DATA AND SOURCES

Data collection involved reviewing published articles on CBCT devices and accessing manufacturer websites. Additional manufacturers were identified through a literature search and by attending scientific and commercial events held in 2023 and 2024. Information on CBCT features was obtained from websites, manuals, and inquiries until February of 2025. Data were categorized and analyzed descriptively and quantitatively to recommend device requirements for dental specialties. Decision support charts were developed for each specialty based on common indications and technical parameters (e.g., field-of-view, scout need, spatial resolution, X-ray exposure parameters, and post-processing tools).

RESULTS

Eighty-seven commercially available CBCT devices from 34 manufacturers across 11 countries were identified, with information confirmed for only 10 companies. Missing data varied, however FOV and voxel size were commonly reported. Tube voltage ranged from 50-120 kV, and tube current mostly varied between 1-17 mA. Dose considerations varied widely, with dose-product-area ranging from 10 to 5600 mGy.cm2 and typical effective dose estimates from 3 to 500 µSv. Decision support charts were created, outlining necessary image acquisition and reconstruction-related parameters for prosthodontics and implant dentistry, periodontology, oral and maxillofacial surgery, pediatric dentistry and orthodontics, and endodontics.

CONCLUSION

This study provides an overview of the technical features of commercially available CBCT devices, highlighting gaps in reconstruction parameters and dose considerations. Tailored recommendations based on patient-specific needs are essential, with clinicians individualizing CBCT acquisition to optimize diagnostic accuracy and minimize biological risks.

CLINICAL SIGNIFICANCE

This study provides valuable insights into commercially available CBCT devices in terms of their features and provides decision support chart to help clinicians select optimal technical parameters tailored to specific dental specialties.

Micro-Computed Tomography Analysis of Reciprocating Systems in Three-Dimensional Models of Mandibular Premolars with Two Canals

Objective: This study investigated the shaping efficiency of four reciprocating systems-WaveOne Gold, Reciproc Blue, Excalibur, and One Reci-in three dimensional (3D) resin models of natural mandibular premolar teeth with two canals. Methods: Forty 3D-printed mandibular premolars (Vertucci configuration type V) were divided into four groups, each of which was assigned one of the reciprocating systems. According to the manufacturer's protocols, each canal was prepared, with pre- and post-instrumentation micro computed tomography (micro-CT) scans evaluating canal volume, surface area, percentage of unprepared canal walls, and resin reduction in the pericervical area. Instrumentation time and screw-in sensation were recorded as qualitative performance indicators. Statistical analysis was performed using one-way ANOVA and chi-square tests with a significance of (p < 0.05). Results: All systems increased canal volume and surface area, primarily in the apical third, with Reciproc Blue and One Reci achieving the largest volume. WaveOne Gold had the highest percentage of unprepared walls (27.03%) and Reciproc Blue the lowest (19.65%), though these differences were not statistically significant (p > 0.05). Reciproc Blue caused the highest pericervical resin loss (22.24%), significantly higher than Excalibur (15.09%) and One Reci (15.17%) (p = 0.035). Reciproc Blue exhibited the highest incidence of screw-in sensation (70%), while WaveOne Gold achieved the shortest instrumentation time (86.7 s), although neither variable showed statistical significance. Conclusions: All systems effectively shaped complex canal anatomies, with Reciproc Blue demonstrating the highest dentin removal and WaveOne Gold proving the most time efficient. Clinically, these findings suggest that instrument selection should balance shaping efficiency with dentin preservation. Minimizing unprepared areas and preserving pericervical dentin are essential for enhancing disinfection and reducing the risk of root fractures, ultimately contributing to the long-term success of endodontic treatment.

Localisation and classification of multi-stage caries on CBCT images with a 3D convolutional neural network

OBJECTIVES

Dental caries remains a significant global health concern. Recognising the diagnostic potential of cone-beam computed tomography (CBCT) in caries assessment, this study aimed to develop an artificial intelligence (AI)-driven tool for accurate caries localisation and classification on CBCT images, thereby enhancing early diagnosis and precise treatment planning.

MATERIALS AND METHODS

A three-dimensional (3D) convolutional neural network (CNN) was developed using a large annotated dataset comprising 1,778 single-tooth CBCT images. The network's performance in localising and classifying multi-stage caries was compared with that of three dentists. Performance metrics included precision, recall, F1-score, Dice similarity coefficient (DSC), and the area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

The proposed CNN achieved overall precision, recall, and DSC values of 0.712, 0.899, and 0.776, respectively, for lesion localisation. In comparison, the average metrics values for the dentists were 0.622, 0.886, and 0.700. For caries classification, the CNN achieved precision, recall, and F1-score values of 0.855, 0.857, and 0.856, respectively, whereas the corresponding values for the dentists were 0.700, 0.684, and 0.678. Overall, the CNN significantly outperformed the dentists in both localisation and classification tasks.

CONCLUSIONS

This study developed a high-performance 3D CNN for the localisation and classification of multi-stage caries on CBCT images. The CNN demonstrated significantly superior diagnostic performance compared to a group of three dentists, underscoring its potential for clinical integration.

CLINICAL RELEVANCE

The integration of AI into CBCT image analysis may improve the efficiency and accuracy of caries diagnosis. The proposed CNN represents a promising tool to enhance early diagnosis and precise treatment planning, potentially supporting clinical decision-making in dental practice.

The influence of endodontic treatment quality on periapical lesions' architecture in cone-beam computed tomography

This study assessed the influence of root canal treatment quality on the architecture of periapical lesions. A total of 121 lesions were involved in this research. Two researchers analysed the surface of the lesions, diameters in three planes, volume and sphericity. The quality of root canal treatment was assessed with PESS index. Non-parametric statistical tests: Mann-Whitney and Spearman rank correlation coefficient were used in this research. Connected lesions of multirooted teeth spread in the coronal plane revealed a positive correlation with coronal seal and root canal filling homogenicity, however their spread in the sagittal plane showed a positive correlation only with root canal filling homogenicity. The quality of root canal treatment has an influence on the periapical lesions' architecture.

C-shaped Canal in Second Mandibular Molar: A Case Report

Root canal treatment is a procedure that is often performed in dental practice, both on single-rooted and multi-rooted teeth. Endodontic treatment of multi-rooted teeth can be challenging due to variations in the root canal system. The most common anatomical variation in mandibular second molars is the C-shaped root canal system. In particular, mandibular molars with joined roots, a longitudinal radicular groove on the buccal and/or lingual root surface, and at least one axial cross-section with a "C-shaped" morphology are considered to have C-shaped morphology. To guarantee high-quality care, medication, and C-shaped canal obturation, we need preliminary radiography or cone beam computed tomography (CBCT) to help us determine the diagnosis and best course of action. The purpose of this article is to show а clinical case of a lower second molar with C-shaped anatomy, in which, with magnification, preliminary radiography, and an appropriate system for root canal preparation and obturation, quality treatment is achieved, with the tooth being functional and preserved in the dentition.

Exploring anatomical uniqueness: A rare case report of the buccomesial groove variation in maxillary lateral incisor and its management

This case report introduces the rare anatomical variation in a maxillary lateral incisor, known as the buccomesial groove (BMG). The BMG is rare and leads to endodontic-periodontal lesions. Due to its subtle presence, funnel-shaped form, and varying depth in the root, it facilitates microbial film adhesion, leading to pathology. A 25-year-old Asian male patient presented with pain in his maxillary left lateral incisor. After comprehensive clinical and radiographic assessments, the diagnosis of pulpal necrosis with symptomatic apical periodontitis associated with BMG in the maxillary left lateral incisor was confirmed. A cone-beam computed tomography preoperatively showed the groove extending from two-thirds of the buccal to the mesial side of the left lateral incisor. This case presents a new anatomical anomaly, highlighting the necessity for precise diagnosis and treatment.

Optimization of Cone-beam Computed Tomography Protocols to Detect the Second Mesiobuccal Canal in the Presence of Artifacts

INTRODUCTION

There is difficulty in identifying the mesiobuccal canal in clinical routine. The use of cone-beam computed tomography (CBCT) helps overcome this difficulty by providing volumetric details of the teeth and surroundings. Thus, the objective of this study was to determine the effectiveness of different CBCT protocols, with different image resolutions, in visualizing the second mesiobuccal canal in maxillary molars in the presence of artifacts.

METHODS

To perform the study, the visualization of the second mesiobuccal canal of 28 maxillary molars with root canal preparation and obturation was used, with the exception of the second mesiobuccal canal. The teeth were placed in a dry maxilla and then scanned with the OP300 MAXIO CBCT unit (4 protocols) and 3D Veraview X800 F150P (3 protocols). Five experienced and blinded evaluators analyzed the images to assess accuracy, sensitivity, and specificity. The presence of the second mesiobuccal canal was confirmed by light microscopy (×50 magnification) of cross-sections of the roots.

RESULTS

Our data showed that the Veraview X800 CT scanner provided better results for accuracy (96%), sensitivity (100%), and specificity (86%). The 50 × 50/0.085 protocol showed the highest sensitivity (78%), specificity (100%), and accuracy (82%). It was possible to visualize the second mesiovestibular canals in both CT scanners tested; however, the 3D Veraview X800 F150P offered better results for the evaluated patterns.

CONCLUSIONS

The best protocol in the presence of artifacts was 80 × 40 FOV and 0.125 voxel size of 3D Veraview X800 F150P.

Comparison of two CBCT analysis techniques with conventional periapical radiographs in assessment of tertiary dentin after indirect pulp capping in young permanent teeth

BACKGROUND AND AIM

To compare two cone beam computed tomography (CBCT) analysis techniques for measuring tertiary dentin (TD) volume, density, and root length increase, after indirect pulp therapy (IPT) in young permanent teeth with conventional periapical radiographs.

DESIGN

Comparative study design: Sixty-nine CBCT scans were taken initially (T1) and after 1 year (T2) of IPT. New CBCT analysis technique A, standardization, segmentation, and registration of T1 and T2 scans were performed using ITK-SNAP and 3D Slicer CMF to measure TD volume (mm3), density (gray-level intensity), and root length increase (mm). In the traditional CBCT analysis technique B, analyses were conducted using the In-Vivo software to calculate TD thickness (mm), radiodensity (HU%), and root length increase (mm). Paired t-test and the intraclass correlation coefficient were calculated to compare and assess the reliability of all techniques.

RESULTS

No significant difference between the two techniques existed in the measurement of TD mineral density (Mean [SD]:A = 22.4 [15.4]; B = 24.4 [15.4]; p = .47). Technique A resulted in significantly higher root length increase values (Mean [SD]: A = 1.3 [0.6]; B = 1.1 [0.5]; p = .03). The two techniques showed acceptable reliability levels (0.76-0.99).

CONCLUSION

CBCT analysis techniques yielded similar findings for mineral density. The new CBCT volumetric analysis technique, although more laborious, produced higher values for root length increase, and allowed for measurement of dentin volume.

Preoperative evaluation of lingual cortical plate thickness and the anatomical relationship of the lingual nerve to the lingual cortical plate via 3T MRI nerve-bone fusion

OBJECTIVES

To evaluate the reliability of 3T MRI nerve-bone fusion in assessing the lingual nerve (LN) and its anatomical relationship to the lingual cortical plate prior to the impacted mandibular third molar (IMTM) extraction.

METHODS

The MRI nerve and bone sequences used in this study were 3D T2-weighted fast field echo (3D-T2-FFE) and fast field echo resembling a CT using restricted echo-spacing (FRACTURE), respectively. Both sequences were performed in 25 subjects, and the resulting 3D-T2-FFE/FRACTURE fusion images were assessed by 2 independent observers. Semi-quantitative analyses included assessments of overall image quality, image artefacts, nerve continuity, and the detectability of 5 intermediate points (IPs). Quantitative analyses included measurements of the lingual cortical plate thickness (LCPT), vertical distance (V1* and V2*), and the closest horizontal distance (CHD) between the LN and the lingual cortical plate. Reliability was evaluated using weighted Cohen's kappa coefficient (κ), intraclass correlation coefficient (ICC), and Bland-Altman plots. Differences in LCPT between 3D-T2-FFE/FRACTURE fusion images and cone-beam computed tomography (CBCT) were compared using independent samples t-tests or Mann-Whitney U tests.

RESULTS

The fusion images demonstrated that the LN continuity score was 3.00 (1.00) (good), with 88% (44/50) of LNs displayed continuously at the IMTM level. Intra-reader agreement for nerve continuity was moderate (κ = 0.527), as was inter-reader agreement (κ = 0.428). The intra-reader and inter-reader agreement for LCPT measurements at the neck, mid-root, and apex of the IMTM were all moderate (ICC > 0.60). Intra-reader agreements for V1*, V2*, and CHD were moderate to excellent (ICC = 0.904, 0.967, and 0.723, respectively), and inter-reader agreements for V1*, V2*, and CHD were also moderate to excellent (ICC = 0.948, 0.941 and 0.623, respectively). The reliability of LCPT measurements between 3D-T2-FFE/FRACTURE fusion and CBCT was moderate (ICC = 0.609-0.796).

CONCLUSIONS

The 3D-T2-FFE/FRACTURE fusion technique demonstrated potential feasibility for the identification of the LN and its relationship to the lingual cortical plate, as well as for the measurement of LCPT. This study has generated a dataset that is capable of simultaneously defining the LN and LCPT.

Prevalence and morphology of middle mesial canals in mandibular first molars and their relationship with anatomical aspects of the mesial root: a CBCT analysis

BACKGROUND

This study aims to investigate the prevalence and morphology of middle mesial canal (MMC) in mandibular first molar (M1M) among a Northwestern Chinese population, and to analyze their relationship with anatomical aspects of the mesial root.

METHODS

Cone beam computed tomography (CBCT) was utilized to evaluate 898 M1Ms and assess the incidence and morphology of MMC. The following parameters for M1M with or without MMC were obtained: the vertical distance between the first appearance of MMC and canal orifices (D), the distance between mesiobuccal (MB) and mesiolingual (ML) canals (D1), the buccolingual width(L1) and mesiodistal width (L2) of mesial roots, and the flatness degree(L1/L2) of mesial roots. The results were statistically analyzed.

RESULTS

The prevalence of MMC was 9.6% when considering the number of teeth and 7.2% when considering individuals. The presence of MMC was not significantly associated with sex (p = 0.993) or age (p = 0.211). Type 1-3-2 emerged as the most prevalent root canal morphology. MMC primarily manifested within 4 mm below the canal orifices. In cases where MMC was present, the MB-ML distance was significantly greater (p = 0.017). Conversely, no significant correlation was found between the presence of MMC and the length, width, or flatness degree of the mesial roots.

CONCLUSIONS

The morphology of MMCs is complex, and most of them exhibit confluent canals. In instances where MMCs are present, the MB-ML distance is significantly larger. For effective detection of MMC, a thorough examination of the area within 4 mm beneath the canal orifice is recommended.

Prevalence and root canal morphology of taurodontism analyzed by cone-beam computed tomography in Northern China

BACKGROUND

To evaluate the prevalence and characteristics of taurodontism in northern China by using cone-beam computed tomography (CBCT) and assisting the treatment.

METHODS

The study involved CBCT scans of 8112 teeth from 507 participants of northern China, comprising 217 males and 290 females aged 18 to 60. Analysis was conducted using Shifman and Chanannel's criteria to assess the prevalence and attributes of taurodontism, examining differences based on tooth position (maxilla and mandible) as well as gender (P < 0.05). Specific morphology including C-shaped canal was recorded. The curvature of the canals was measured using a modified Schneider method. Moreover, we reported two failure cases with taurodontism referred to a retreatment.

RESULTS

Taurodontism was observed in 113 participants, affecting 23.50% of the males and 21.38% of the females in at least one tooth (P > 0.05). The prevalence was significant higher in maxilla (P < 0.05). The highest incidence of taurodontism was detected in premolars, 9.86% in the maxillary first premolars, and in molars, with 3.94% in the maxillary first molars. Regarding canal curvature, a higher incidence of curved canal could be found in maxillary and mandibular molars of taurodontism (47.50-66.67%), alongside an elevated prevalence of C-shaped taurodontism in mandibular second molars (71.43%). After follow-up, the healing response was satisfactory in both cases.

CONCLUSION

The study highlighted a higher incidence of taurodontism in maxilla, indicating a significant association between taurodontism, C-shaped characteristics, and canal curvature. Dentists are advised to carefully consider the presence of special morphologies during taurodontism treatment.

Cone-Beam Computed Tomographic Scan-based Assessment of the Correlation between the Location of Caries and Pulp Canal Obliteration: An Aid to Treatment Planning

INTRODUCTION

This study aimed to determine the correlation between proximal caries and the extent and site of pulp canal obliteration (PCO) in cone-beam computed tomographic (CBCT) scans of mandibular molar teeth.

METHODS

A total of 1491 CBCT scans of patients 18-49 years of age were selected from the database (2002-2022). From them, 328 teeth with proximal caries and satisfying inclusion criteria were evaluated by 2 calibrated evaluators. PCO was observed in the sagittal and coronal planes. PCO and proximal caries were compared concerning different age groups, sexes, and sites using an independent sample t test.

RESULTS

The prevalence of PCO among patients with proximal caries is 47%. In mesial proximal caries, the extent of PCO is significantly greater in the distal root canal (73.4%), whereas in distal proximal caries, PCO is more often found in the mesial canal (77.3%). The mean extent of intraradicular calcification was higher in the distal canal (P < .001). Moreover, mesial proximal caries showed a greater extent of intraradicular obliteration (P < .001). The probability of developing PCO was significantly higher in females (P = .003).

CONCLUSIONS

Within the limitations of this study, it can be concluded that the extent of calcification is more common on the opposite side of the location of the proximal caries. Moreover, such intraradicular calcification is greater in a distal canal compared to a mesial canal. Sex plays a significant role in the calcification process, showing higher predilection in females compared to males.

Effect of Calcium Hydroxide Versus Double Antibiotic Paste on Endodontic Treatment Outcomes in Teeth With Large Periapical Lesions: A Triple-Blind Randomized Clinical Trial

Objective: The successful management of necrotic pulps and apical periodontitis poses a tough challenge in endodontic therapy, as it involves addressing compromised tooth vitality and microbial invasion of root canal systems. Failure to effectively treat these conditions can lead to persistent infection and severe patient discomfort. The efficacy of double antibiotic paste (DAP), a mixture of ciprofloxacin and metronidazole, was evaluated and compared to calcium hydroxide (CH) by assessing radiographic and clinical outcomes of nonsurgical endodontic treatment in cases with necrotic pulps and the presence of apical periodontitis. Methods: Thirty maxillary anterior teeth with necrotic pulps and apical periodontitis (periapical index [PAI] = 5) were divided randomly into two experimental groups. The first group received CH dressing, while the other group filled with DAP as intracanal medicament. After 3 weeks, medicaments were removed, and teeth were obturated in both groups. Teeth were assessed clinically and radiographically at 6-month and 12-month follow-ups. A chi-square test was performed to compare the outcome between the groups. Results: None of the teeth showed complete healing in a 6-month follow-up. At the 12-month follow-up, six samples in the DAP group showed complete healing of the periapical (PA) lesion, while none of the samples in the CH group were completely healed. The PA healing outcome was as follows: in the DAP group, 40% of cases were healed, 60% healing, and 0% diseased, while in the CH group, 0% healed, 93.3% healing, and 6.7% diseased. The results of the two experimental groups in 12 months differed significantly (p  < 0.05). Conclusion: DAP group has shown significantly better outcomes compared to CH as intracanal medicament in the treatment of teeth with PA lesions. This finding suggests that DAP may offer a more effective therapeutic approach in managing necrotic pulps and apical periodontitis, potentially improving patient outcomes and treatment success rates. Trial Registration: Clinical Trial Registry identifier: IRCT2015060822615N1.

Detecting Mandible Fractures in CBCT Scans Using a 3-Stage Neural Network

After nasal bone fractures, fractures of the mandible are the most frequently encountered injuries of the facial skeleton. Accurate identification of fracture locations is critical for effectively managing these injuries. To address this need, JawFracNet, an innovative artificial intelligence method, has been developed to enable automated detection of mandibular fractures in cone-beam computed tomography (CBCT) scans. JawFracNet employs a 3-stage neural network model that processes 3-dimensional patches from a CBCT scan. Stage 1 predicts a segmentation mask of the mandible in a patch, which is subsequently used in stage 2 to predict a segmentation of the fractures and in stage 3 to classify whether the patch contains any fracture. The final output of JawFracNet is the fracture segmentation of the entire scan, obtained by aggregating and unifying voxel-level and patch-level predictions. A total of 164 CBCT scans without mandibular fractures and 171 CBCT scans with mandibular fractures were included in this study. Evaluation of JawFracNet demonstrated a precision of 0.978 and a sensitivity of 0.956 in detecting mandibular fractures. The current study proposes the first benchmark for mandibular fracture detection in CBCT scans. Straightforward replication is promoted by publicly sharing the code and providing access to JawFracNet on grand-challenge.org.

Automatic jawbone structure segmentation on dental CBCT images via deep learning

OBJECTIVES

This study developed and evaluated a two-stage deep learning-based system for automatic segmentation of mandibular cortical bone, mandibular cancellous bone, maxillary cortical bone and maxillary cancellous bone on cone beam computed tomography (CBCT) images.

MATERIALS AND METHODS

A dataset containing 155 CBCT scans acquired with different parameters was obtained. A two-stage deep learning-based system was developed for automatically segmenting jawbone structures. The Dice similarity coefficient (DSC) and average symmetric surface distance (ASSD) were used to assess the segmentation performance of the system by comparing the automatic segmentation results with the ground truth. The impact of dental and quality abnormalities on segmentation performance was analysed, and a comparison of automatic segmentation (AS) with manually refined segmentation (MRS) was reported.

RESULTS

The system achieved promising segmentation performance, with average DSC values of 93.69%, 96.83%, 86.14% and 95.57% and average ASSD values of 0.13 mm, 0.16 mm, 0.29 mm and 0.41 mm for the mandibular cortical bone, mandibular cancellous bone, maxillary cortical bone and maxillary cancellous bone, respectively. Quality abnormalities had a negative impact on segmentation performance. The performance metrics (DSCs > 98.8% and ASSDs < 0.1 mm) indicated high overlap between the AS and MRS.

CONCLUSION

The proposed system offers an accurate and time-efficient method for segmenting jawbone structures on CBCT images.

CLINICAL RELEVANCE

Automatically segmenting jawbone structures is essential in most digital dental workflows. The proposed system has considerable potential for application in digital clinical workflows to assist dentists in making more accurate diagnoses and developing patient-specific treatment plans.

Literature review and case study: unveiling the complexities of mandibular second molar with three distal canals

The occurrence of morphological deviations in root canal anatomy is challenging and can influence treatment outcomes. While mandibular second molars typically have 2 roots and 3 canals, a unique case emerged in a 23-year-old Indian male with a symptomatic permanent left mandibular second molar showing three distal, two mesial canals, and two roots. The tooth presented as non-mobile but tender on percussion. The patient was diagnosed with symptomatic irreversible pulpitis with symptomatic apical periodontitis. The presence of mid distal canal was radiographically and visually confirmed with the aid of limited FOV cone-beam computed tomography and the dental operating microscope. Successful nonsurgical root canal treatment with 6-month follow-up has been documented in this case report.

Machine learning and deep learning models for the diagnosis of apical periodontitis: a scoping review

OBJECTIVES

To assess the existing literature on the use of machine learning (ML) and deep learning (DL) models for diagnosing apical periodontitis (AP) in humans.

MATERIALS AND METHODS

A scoping review was conducted following the Arksey and O'Malley framework. The PubMed, SCOPUS, and Web of Science databases were searched, focusing on articles using ML/DL approaches for AP diagnosis. No restrictions were applied. Two independent reviewers screened publications and charted data in predefined Excel tables for analysis.

RESULTS

Nineteen publications focused on diagnosing AP by identifying periapical radiolucent lesions (PRLs) in dental radiographs were included. The average sensitivity and specificity for reviewed models were 83% and 90%, respectively. Only three studies explored the direct impact of artificial intelligence (AI) assistance on clinicians' diagnostic performance. Both consistently showed improved sensitivity without compromising specificity. Significant variability in dataset sizes, labeling techniques, and algorithm configurations was noticed.

CONCLUSIONS

Findings affirm AI models' effectiveness and transformative potential in diagnosing AP by improving the accurate detection of periapical radiolucencies using dental radiographs. However, the lack of standardized reporting on crucial aspects of methodology and performance metrics prevents establishing a definitive diagnostic approach using AI. Further studies are needed to expand AI applications in AP diagnosis beyond radiographic analysis.

CLINICAL RELEVANCE

AI can potentially improve diagnostic accuracy in AP diagnosis by enhancing the sensitivity of PRL detection in dental radiographs without compromising specificity.

Palatal root endodontic microsurgery in maxillary molars using the palatal approach: a case study

BACKGROUND

In clinical practice, the buccal approach is typically the primary choice for endodontic microsurgery. Owing to the thickness of the buccal bone plate, the distance between the buccal bone plate and palatal lesion location, and soft tissue traction, the palatal approach may be more suitable for microsurgery for apical periodontitis of the palatal roots of the maxillary molars. However, the length of the palatal root, location of the greater palatine artery (GPA) and foramen (GPF), and surgical field of observation make palatal surgery challenging.

CASE PRESENTATION

With the aid of Cone-beam computed tomography imaging, the palatal approach was successfully applied in nine cases of endodontic microsurgery of the palatal root of a maxillary molar with a periapical lesion in Hangzhou Stomatology Hospital from January to December 2022.

CONCLUSIONS

Complete healing was assessed based on clinical symptoms and radiographic images at the 3- and 24-month follow-up visits in all nine cases. Several tips have been proposed including surgical positioning, incision design, palate flap modification, bone removal, and root-end resection.

Leveraging Pretrained Transformers for Efficient Segmentation and Lesion Detection in Cone-Beam Computed Tomography Scans

INTRODUCTION

Cone-beam computed tomography (CBCT) is widely used to detect jaw lesions, although CBCT interpretation is time-consuming and challenging. Artificial intelligence for CBCT segmentation may improve lesion detection accuracy. However, consistent automated lesion detection remains difficult, especially with limited training data. This study aimed to assess the applicability of pretrained transformer-based architectures for semantic segmentation of CBCT volumes when applied to periapical lesion detection.

METHODS

CBCT volumes (n = 138) were collected and annotated by expert clinicians using 5 labels - "lesion," "restorative material," "bone," "tooth structure," and "background." U-Net (convolutional neural network-based) and Swin-UNETR (transformer-based) models, pretrained (Swin-UNETR-PRETRAIN), and from scratch (Swin-UNETR-SCRATCH), were trained with subsets of the annotated CBCTs. These models were then evaluated for semantic segmentation performance using the Sørensen-Dice coefficient (DICE), lesion detection performance using sensitivity and specificity, and training sample size requirements by comparing models trained with 20, 40, 60, or 103 samples.

RESULTS

Trained with 103 samples, Swin-UNETR-PRETRAIN achieved a DICE of 0.8512 for "lesion," 0.8282 for "restorative materials," 0.9178 for "bone," 0.9029 for "tooth structure," and 0.9901 for "background." "Lesion" DICE was statistically similar between Swin-UNETR-PRETRAIN trained with 103 and 60 images (P > .05), with the latter achieving 1.00 sensitivity and 0.94 specificity in lesion detection. With small training sets, Swin-UNETR-PRETRAIN outperformed Swin-UNETR-SCRATCH in DICE over all labels (P < .001 [n = 20], P < .001 [n = 40]), and U-Net in lesion detection specificity (P = .006 [n = 20], P = .031 [n = 40]).

CONCLUSIONS

Transformer-based Swin-UNETR architectures allowed for excellent semantic segmentation and periapical lesion detection. Pretrained, it may provide an alternative with smaller training datasets compared to classic U-Net architectures.

Importance of 3D imaging in the evaluation of root formation following regenerative endodontic procedures: a case series

The follow-up of teeth that have undergone regenerative endodontic procedures through radiographic imaging is crucial for evaluating their success and determining their future prognosis. The periapical radiographs stand out as the primary tool for this task and are also recommended by the existing guidelines. However, two-dimensional (2D) imaging may not reveal the findings accurately, mimicking the root formation success which may not be true otherwise when assessed using cone beam CT (CBCT) imaging. This case series featuring two instances underscores the significance of CBCT in identifying such signs of failure, particularly when they might be obscured in 2D imaging.

Current Endodontic Practices among Romanian Dental Practitioners: A Cross-Sectional Study

Root canal therapy (RCT) is usually performed in Romania by general dentists (GDPs) because they are more readily available and more reasonably priced than endodontists. Concerns have been raised about the quality of RCTs performed by GDPs, possibly due to insufficient equipment or knowledge; therefore, this study aims to investigate current endodontic practices in Romania. Materials and Methods: A cross-sectional study was conducted via a questionnaire distributed to 400 randomly selected Romanian dentists, with 285 fully validated completed responses (71.25% response rate). Respondents were grouped by speciality, and statistical analysis, including cross-tabulation and the χ2 (chi-square) test, was used, with a significance level set at p ≤ 0.05 for all tests. Results: Significant differences were found in the use of magnification, rubber dam, sodium hypochlorite concentration, and bioceramics (p < 0.001). No significant differences were observed in preferences for measuring working length (p = 0.166) or rotary instrument motion (p = 0.289). Approximately 6% of the respondents used laser technology with no significant difference across specialities (p = 0.571). Additionally, 77.9% preferred using sodium hypochlorite, with no significant difference between groups (p = 0.006) regarding concentration. Conclusions: Most participants, including GDPs, use modern equipment and techniques during RCT, indicating their awareness and competence in current endodontic practices.

Worldwide Prevalence of Single-rooted with a Single Root Canal and Four-rooted Configurations in Maxillary Molars: A Multi-center Cross-sectional Study with Meta-analysis

INTRODUCTION

To evaluate the prevalence of single root with a single root canal and four-root configurations in the maxillary first and second molars, and analyze how geographic region, ethnicity, sex, and age impact these outcomes.

METHODS

Researchers from 44 nations examined 26,400 maxillary molars using cone-beam computed tomography scans to gather data on the proportions of single roots with single canals and four-root configurations. All observers underwent prior calibration regarding the step-by-step assessment protocol and anatomical concepts to ensure consistent evaluations across all assessed locations. Tests were conducted to evaluate the intraobserver and interobserver reliability. Demographic data including ethnicity, gender, and age were collected for each participant. The potential impact of imaging voxel size and field-of-view on bias was also assessed. The primary results were depicted as odds ratios and untransformed proportion forest plots with 95% confidence intervals. Additionally, a meta-analysis was performed to compare various subgroups and identify sources of variation among them. Statistical significance was set at 5%.

RESULTS

The prevalence of single-rooted with a single canal and four-rooted configurations in the maxillary first molar was 0.16% and 0.28%, respectively, while in the maxillary second molar, it was 2.56% and 0.83%. Males tended to exhibit lower percentages of single roots with a single canal (P < .05) and higher percentages of four-rooted configurations (P > .05) in the second molar, whereas the African subgroup displayed lower proportions for both configurations. Additionally, in both teeth, single roots with a single canal were more prevalent among older patients. Voxel size and field-of-view did not significantly influence the results (P > .05).

CONCLUSIONS

The proportions of single-rooted with a single canal and four-rooted configurations were low, and demographic factors such as geographic region, ethnicity, sex, and age may have influenced the outcomes for the maxillary second molar.

Construction and Evaluation of an AI-based CBCT Resolution Optimization Technique for Extracted Teeth

INTRODUCTION

In dental clinical practice, cone-beam computed tomography (CBCT) is commonly used to assist practitioners to recognize the complex morphology of root canal systems; however, because of its resolution limitations, certain small anatomical structures still cannot be accurately recognized on CBCT. The purpose of this study was to perform image super-resolution (SR) processing on CBCT images of extracted human teeth with the help of a deep learning model, and to compare the differences among CBCT, super-resolution computed tomography (SRCT), and micro-computed tomography (Micro-CT) images through three-dimensional reconstruction.

METHODS

The deep learning model (Basicvsr++) was selected and modified. The dataset consisted of 171 extracted teeth that met inclusion criteria, with 40 maxillary first molars as the training set and 40 maxillary first molars as well as 91 teeth from other tooth positions as the external test set. The corresponding CBCT, SRCT, and Micro-CT images of each tooth in test sets were reconstructed using Mimics Research 17.0, and the root canal recognition rates in the 3 groups were recorded. The following parameters were measured: volume of hard tissue (V1), volume of pulp chamber and root canal system (V2), length of visible root canals under orifice (VL-X, where X represents the specific root canal), and intersection angle between coronal axis of canal and long axis of tooth (∠X, where X represents the specific root canal). Data were statistically analyzed between CBCT and SRCT images using paired sample t-test and Wilcoxon test analysis, with the measurement from Micro-CT images as the gold standard.

RESULTS

Images from all tested teeth were successfully processed with the SR program. In 4-canal maxillary first molar, identification of MB2 was 72% (18/25) in CBCT group, 92% (23/25) in SRCT group, and 100% (25/25) in Micro-CT group. The difference of hard tissue volume between SRCT and Micro-CT was significantly smaller than that between CBCT and Micro-CT in all tested teeth except 4-canal mandibular first molar (P < .05). Similar results were obtained in volume of pulp chamber and root canal system in all tested teeth (P < .05). As for length of visible root canals under orifice, the difference between SRCT and Micro-CT was significantly smaller than that between CBCT and Micro-CT (P < .05) in most root canals.

CONCLUSIONS

The deep learning model developed in this study helps to optimize the root canal morphology of extracted teeth in CBCT. And it may be helpful for the identification of MB2 in the maxillary first molar.

Identification of Root Canal Morphology in Fused-rooted Mandibular Second Molars From X-ray Images Based on Deep Learning

INTRODUCTION

Understanding the intricate anatomical morphology of fused-rooted mandibular second molars (MSMs) is essential for root canal treatment. The present study utilized a deep learning approach to identify the three-dimensional root canal morphology of MSMs from two-dimensional X-ray images.

METHODS

A total of 271 fused-rooted MSMs were included in the study. Micro-computed tomography reconstruction images and two-dimensional X-ray projection images were obtained. The ground truth of three-dimensional root canal morphology was determined through micro-computed tomography images, which were classified into merging, symmetrical, and asymmetrical types. To amplify the X-ray image dataset, traditional augmentation techniques from the python package Augmentor and a multiangle projection method were employed. Identification of root canal morphology was conducted using the pretrained VGG19, ResNet18, ResNet50, and EfficientNet-b5 on X-ray images. The classification results from convolutional neural networks (CNNs) were then compared with those performed by endodontic residents.

RESULTS

The multiangle projection augmentation method outperformed the traditional approach in all CNNs except for EfficientNet-b5. ResNet18 combined with the multiangle projection method outperformed all other combinations, with an overall accuracy of 79.25%. In specific classifications, accuracies of 81.13%, 86.79%, and 90.57% were achieved for merging, symmetrical, and asymmetrical types, respectively. Notably, CNNs surpassed endodontic residents in classification performance; the average accuracy for endodontic residents was only 60.38% (P < .05).

CONCLUSIONS

CNNs were more effective than endodontic residents in identifying the three-dimensional root canal morphology of MSMs. The result indicates that CNNs possess the capacity to employ two-dimensional images effectively in aiding three-dimensional diagnoses.

Selective root canal retreatment of a maxillary first molar: a case report with a 9-year follow up

Traditional endodontic retreatments usually target the entire root canal system. In contrast, selective root canal retreatment presents a new, targeted alternative that offers a less invasive solution. However, its promising approach faces potential obstacles due to a lack of long-term data, which might affect its widespread acceptance. This case report adds to the existing body of literature by offering an in-depth analysis of a long-term outcome following selective non-surgical retreatment, thereby bridging an important gap in knowledge. A 59-year-old male presented with post-treatment apical periodontitis (PTAP) in a maxillary first molar. Initial clinical examination revealed the patient was symptomatic, and the tooth responded negative to thermal tests and positive to vertical percussion. Radiographic assessment identified a radiolucency confined to the mesiobuccal root. No radiolucencies or signs of inflammation were observed in the distobuccal and palatal roots. These findings led to the decision to selectively retreat the mesiobuccal root non-surgically. This targeted approach aimed at addressing the inflammation while preserving the integrity of unaffected areas. The patient received selective non-surgical retreatment on the mesiobuccal root. During a nine-year follow-up, the patient remained asymptomatic, as confirmed by clinical observation. Periapical radiograph and Cone Beam Computed Tomography (CBCT) scan demonstrated complete healing of the treated root. Importantly, the untreated roots showed no signs or symptoms of apical periodontitis. This underscores the efficacy of the targeted treatment and its successful resolution of the inflammation. This case report aimed to show the long-term effectiveness and minimally invasive nature of selective root canal retreatment to address PTAP. It focused on the method's capacity to preserve tooth structure with minimum intervention. The positive outcomes highlight the urgent need for more controlled studies. Such research would confirm the advantages of selective retreatment, with the goal of improving endodontic protocols and patient care.

Assessment of endodontic treatment and prevalence of apical periodontitis using cone-beam computed tomography: a cross-sectional study

Purpose

The purpose of this study was a retrospective cross-sectional study of the Polish subpopulation, performed to evaluate the quality of endodontic treatment (ET) and the condition of the periapical tissues of permanent teeth based on cone-beam computed tomography (CBCT) images.

Material and methods

The retrospective study included a group of patients who underwent CBCT at the University Dental Clinic of the Pomeranian Medical University in Szczecin. An endodontically treated tooth index (ETTI) was used to evaluate ET. Once apical periodontitis was recognised, the size, extent, and ratio of adjacent anatomical structures were assessed using the complex periapical index (COPI).

Results

Analysis of the CBCT images showed that ET was performed in 9.9% of the teeth examined, of which 52.7% of the canals were treated correctly, while 28.1% of the root canals were found to be underfilled, 6.8% were overfilled, 9.3% of the root canals were not obturated at all, and in 3.1% of the teeth examined, the filling material was only visible in the pulp chamber. Apical periodontitis was observed in 6% of all teeth examined, while the percentage of teeth following ET was 38.5%.

Conclusions

The quality of the ET provided to the Polish subpopulation is unsatisfactory. Lack of root canal filling homogeneity is a significant risk factor for ET failure. Improper ET and poor quality of crown restoration after ET have an impact on the increased risk of occurrence, size, degree of root coverage, and extent of inflammatory periapical lesions in relation to adjacent anatomical structures.

Distribution and influencing factors of pulp stones based on CBCT: a retrospective observational study from southwest China

BACKGROUND

Pulp stones are a type of pulp calcification, the presence of which tends to hinder endodontic treatment. Thus, this retrospective study aimed to analyze the distribution of pulp stones in the population in southwest China and identify the influencing factors.

MATERIALS

Cone-beam computed tomography (CBCT) scans of 5066 teeth of 200 patients (91 males and 109 females) aged 16-45 years were evaluated. Pulp stones were marked as either present or absent when distinct radiopaque masses were found in the pulp cavity, then evaluated the occurrence of pulp stones with regard to tooth type, sex, age group, and contact it with tooth status. The Pearson chi-square test and nonparametric test were used for statistical analysis.

RESULTS

Pulp stones were detected in 49.0% of patients and 7.4% of teeth, respectively. The incidence in females was 1.9 times higher than in males (OR = 1.9, 95% CI = 1.1-3.3, p = 0.001). Pulp stones were most prevalent in patients 36-45 years of age. Furthermore, in the age range of 16-45 years, the likelihood of finding pulp stones increased 1.1 times per year with age (OR = 1.1, 95% CI = 1.0-1.1, p = 0.032). A higher incidence of pulp stones was observed in the maxilla and molars. Of the 5066 teeth studied, pulp stones were more common in non-intact teeth.

CONCLUSION

Nearly half of the population in southwest China had pulp stones. Pulp stones were found significantly more often in females, maxilla, and non-intact teeth, and their frequency increased with age. For dentists, understanding the distribution of pulp stones is crucial for the proper design of root canal treatment (RCT).

TRIAL REGISTRATION

This study was approved by the Ethics Committee of the Affiliated Hospital of Stomatology, Southwest Medical University (certificate number: 20220818001).

Influence of root shape on canal complexity at the mandibular molar apical surgical resection level: A micro-CT study

OBJECTIVES

This study aimed to investigate the relationship between the aspect ratios of mandibular molar roots at the apical 3-mm level and their root canal complexity.

DESIGN

This study used micro-CT imaging to analyze 163 two-rooted mandibular molars. The aspect ratios of the roots at the apical 3-mm level were categorized as "< 2.75" or "≥ 2.75" (mesial) and "< 1.75" or "≥ 1.75" (distal). A two-dimensional (2D) analysis focused on four apical axial cross-section levels to determine the presence of main and accessory canals and isthmus. Additionally, a three-dimensional (3D) assessment of the apical 4-mm of both roots examined main and accessory canals, apical foramina, apical deltas, and middle mesial canals.

RESULTS

Mesial roots with aspect ratios ≥ 2.75 showed a higher number of main canals at all levels compared to those with aspect ratios < 2.75 at the 3-mm level. Additionally, the ≥ 2.75 group exhibited more accessory canals and a higher average number of accessory canals. The 3D assessment confirmed significantly more accessory canals and apical foramina in the ≥ 2.75 group. The prevalence of roots with apical deltas was nearly double in the ≥ 2.75 group, and middle mesial canals were exclusively found in this group. In the distal root, the ≥ 1.75 group showed a significantly higher number of main canals at all axial levels. No significant differences were observed between groups in terms of accessory canals, apical foramina, or deltas.

CONCLUSIONS

A higher root aspect ratio is related to higher anatomical complexity.

Prevalence of Apical Periodontitis in Saudi Arabia: A Systematic Review and Meta-analysis

Objective

This systematic review was aimed to assess the prevalence of apical periodontitis (AP) in Saudi Arabia, focusing on individual-level prevalence and the frequency of AP in endodontically versus untreated teeth.

Methods

This review followed the PRISMA guidelines and involved searches in several databases, including PubMed-MEDLINE, Cochrane-CENTRAL, and EMBASE, without date restrictions until August 19th, 2023. Eligibility criteria encompassed studies using CBCT, panoramic, and periapical radiographs to diagnose AP in the Saudi population. The meta-analysis employed a random-effects model due to high heterogeneity among studies.

Results

From 359 records, 13 studies were included, indicating a 40% prevalence of AP in individuals and a 6% prevalence across all teeth within the Saudi population. Root canal-treated teeth demonstrated a higher prevalence at 47%. The data revealed a substantial prevalence of AP compared to global averages, with first molars being the most affected. Studies showed moderate risk of bias and significant heterogeneity.

Conclusion

The high occurrence of AP in Saudi Arabia, particularly in root-treated teeth, emphasizes the need for enhanced endodontic care and more accurate diagnostics. Urgent improvements in dental health policies and further research are essential to understand AP's impact and improve oral health outcomes.

Advancements in guided surgical endodontics: A scoping review of case report and case series and research implications

This scoping review examined current case series and reports on guided surgical endodontic applications in order to provide a critical platform for future research. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews guidelines were followed. A search on PubMed and Scopus yielded 611 articles, with 17 case reports and 1 series meeting inclusion criteria. Overall, guided surgery addressed anatomical complexities, with 15 articles employing static protocols and 3 dynamic. Results showed minimal iatrogenic errors and reduced chair time, with no postoperative issues reported. Within the cases described, guided endodontic surgery exhibited satisfactory results in management of anatomical complex cases. Cost-effectiveness, the need for adequate follow-up, procedure's reproducibility and accuracy, and objective measurement of the reduction in operative times and iatrogenic errors are some of the limitations in the current reports that need to be considered for planning of future experimental and cohort studies.

Evaluating tooth segmentation accuracy and time efficiency in CBCT images using artificial intelligence: A systematic review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the current performance of artificial intelligence (AI)-based methods for tooth segmentation in three-dimensional cone-beam computed tomography (CBCT) images, with a focus on their accuracy and efficiency compared to those of manual segmentation techniques.

DATA

The data analyzed in this review consisted of a wide range of research studies utilizing AI algorithms for tooth segmentation in CBCT images. Meta-analysis was performed, focusing on the evaluation of the segmentation results using the dice similarity coefficient (DSC).

SOURCES

PubMed, Embase, Scopus, Web of Science, and IEEE Explore were comprehensively searched to identify relevant studies. The initial search yielded 5642 entries, and subsequent screening and selection processes led to the inclusion of 35 studies in the systematic review. Among the various segmentation methods employed, convolutional neural networks, particularly the U-net model, are the most commonly utilized. The pooled effect of the DSC score for tooth segmentation was 0.95 (95 %CI 0.94 to 0.96). Furthermore, seven papers provided insights into the time required for segmentation, which ranged from 1.5 s to 3.4 min when utilizing AI techniques.

CONCLUSIONS

AI models demonstrated favorable accuracy in automatically segmenting teeth from CBCT images while reducing the time required for the process. Nevertheless, correction methods for metal artifacts and tooth structure segmentation using different imaging modalities should be addressed in future studies.

CLINICAL SIGNIFICANCE

AI algorithms have great potential for precise tooth measurements, orthodontic treatment planning, dental implant placement, and other dental procedures that require accurate tooth delineation. These advances have contributed to improved clinical outcomes and patient care in dental practice.

Capabilities of Cephalometric Methods to Study X-rays in Three-Dimensional Space (Review)

The aim of the study was a systematic review of modern methods of three-dimensional cephalometric analysis, and the assessment of their efficiency. The scientific papers describing modern diagnostic methods of MFA in dental practice were searched in databases PubMed, Web of Science, eLIBRARY.RU, as well as in a searching system Google Scholar by the following key words: three-dimensional cephalometry, three-dimensional cephalometric analysis, orthodontics, asymmetric deformities, maxillofacial anomalies, 3D cephalometry, CBCT. The literature analysis showed many methods of cephalometric analysis described as three-dimensional to use two-dimensional reformates for measurements. True three-dimensional methods are not applicable for practical purposes due to the fragmentary nature of the studies. There is the disunity in choosing landmarks and supporting planes that makes the diagnosis difficult and costly. The major issue is the lack of uniform standards for tree-dimensional measurements of anatomical structures of the skull, and the data revealed can be compared to them. In this regard, the use of artificial neuron networks and in-depth study technologies to process three-dimensional images and determining standard indicators appear to be promising.

Identification and classification of pulp calcifications in posterior teeth according to dental condition using digital panoramic radiography and cone beam CT

OBJECTIVE

To compare digital panoramic radiography (DPR) and cone beam CT (CBCT) in the detection and classification of pulp calcifications in posterior teeth in relation to tooth condition and its location.

METHODS

Two hundred and fifty patients with simultaneous DPR and CBCT scans were selected from a dental image bank. For each posterior tooth, its condition was registered (healthy, restored, or decayed). The presence of calcifications was assessed and classified according to location (coronal or radicular) and type (total obliteration, partial obliteration, narrowing, and no calcification). Chi-square and McNemar tests were used to compare DPR and CBCT results, with a significance level of 5%. DPR diagnostic values were calculated using CBCT as reference.

RESULTS

Decayed and restored teeth showed a significantly (P < .001) higher prevalence of pulp calcifications than healthy teeth in both imaging exams. There was a significant discrepancy between the imaging modalities in the identification of calcifications (P < .001), especially for radicular calcifications of maxillary teeth (DPR = 55.2%; CBCT = 30.9%). In the case of coronal calcifications, there was a greater discrepancy between CBCT and DPR in the mandibular teeth (10.7%) than in the maxillary teeth (7.7%). Overall, DPR presents higher sensitivity (0.855) than specificity (0.483) for pulp calcifications detection.

CONCLUSION

DPR considerably overestimates pulp calcifications in posterior teeth, as compared to CBCT. A higher prevalence of pulp calcifications is related to decayed and restored teeth.

The effect of cone beam computerized tomography voxel size and the presence of root filling on the assessment of middle mesial canals in mandibular molar teeth

INTRODUCTION

The study aims to compare the detection of the middle mesial canal (MMC) in mandibular molar teeth using cone beam computed tomography (CBCT) with different voxel sizes when the mesiobuccal (MB) and mesiolingual (ML) canals have three distinct phases (unpreparation, preparation and obturation and the removal of the obturation and repreparation).

METHODS

Two hundred forty-two extracted human mandibular molars were collected and kept in a physiological saline solution prior to use. 0.2-, 0.28- and 0.35-mm voxel sizes CBCT (n = 242) were performed in three phases (Ph): Ph1, no MB and ML canal preparation or obturation; Ph2, after MB and ML canals preparation and obturation; and Ph3, after the removal of the obturation of MB and ML canals and canals repreparation. Images were analyzed using OnDemand3D® software. After the CBCT acquisition in Ph3, all the samples were clarified to visualize the presence of the MMC directly. A blinded, previously calibrated examiner analyzed all the images.

RESULTS

The MMC was detected in 15 of the 242 teeth after the clearing technique. The lowest MMC detection rate was observed at 0.35-mm voxel size regardless of the ML and MB canal condition, while the highest was observed at 0.2-mm voxel size (P < 0.05). There is no statistically significant difference between 0.2-mm and 0.28-mm voxel sizes (P > 0.05). In all voxel sizes, the highest rate of detectability of the MMC was seen in Phase 1, while the lowest was in Phase 2.

CONCLUSIONS

It may be appropriate to take a 0.20-mm voxel size CBCT image, especially after the removal of root canal filling.

CLINICAL RELEVANCE

An appropriate CBCT voxel size and the absence of root canal filling in the root canal system help to detect the missing MMC.

Pulp stones in unerupted teeth: a retrospective analysis using cone-beam computed tomography

BACKGROUND

A pulp stone is a calcified mass that develops in the dental pulp of any tooth. Despite many studies examining the relationship between pulp stone formation and non-oral factors, the methods used in these studies have been unable to explain the exact role of these factors alone as distinct from probable effects within the oral cavity environment. Considering that totally unerupted (impacted or developing) teeth are unexposed to the oral cavity's environmental and functional conditions, they provide a more suitable material for studying the effects of these non-oral factors on pulp stone formation. This research study aimed to investigate pulp stones in unerupted teeth and the associated factors in a Saudi subpopulation.

METHODS

The study included 644 cone-beam computed tomography images, with 496 (50.9%) maxillary and 479 (49.1%) mandibular teeth. Of the investigated patients, 293 (45.5%) were men, and 351 (54.5%) were women. The age range was 15-76 years. A chi-square test was used to investigate the associations between pulp stones and age, gender, and history of systemic disease and chronic medication use.

RESULTS

Pulp stones in unerupted teeth were present in 24.2% of the examined dental jaws and 18.6% of the examined teeth. There was no statistically significant relationship between pulp stones and gender (p > 0.05). A significantly greater percentage of pulp stones were found with increasing age (p = 0.000). Additionally, a significantly increased number of pulp stones was observed in patients with systemic diseases and chronic medications (p < 0.05).

CONCLUSIONS

The results support the idea that pulp stones can be present in any type of unerupted tooth. This study provides additional evidence of the increased incidence of pulp stones with age, systemic disease, and chronic medications.

Three-dimensional assessment of obturation volume in lateral canals after three obturation techniques with bioceramic sealer: an in vitro comparative study

OBJECTIVE

This study aimed to evaluate the obturation ability of simulated lateral canal in mandibular premolars at three levels (3, 5, and 7 mm) from the apex using gutta-percha and BC Sealer HiFlow (BCHiF) with different obturation techniques, including continuous wave compaction (CWC), cold lateral condensation (CLC), and single cone (SC) techniques, by a 3D assessment method of the obturation volume with cone beam computed tomography (CBCT) and MIMICS software analysis.

METHODS

Thirty intact human mandibular premolars were decoronated, instrumented up to #30 taper 4%, and uniformly irrigated with 5.25% NaOCl and 17% EDTA. Six simulated lateral canals (3 pairs) were prepared at 3, 5, and 7 mm from the apex in each root, using #10 modified C-file. CBCT images were obtained, and lateral canal volumes were calculated using MIMICS software. The samples were divided into three groups: CWC (n = 10), CLC (n = 10), and SC (n = 10). All groups were obturated with BCHiF and gutta-percha. Another CBCT image was taken post-obturation, and 3D lateral canal obturation volume percentages were calculated using MIMICS software. Data were analyzed using SPSS software with One-way ANOVA and Sidak tests (α = 0.05).

RESULTS

Significant differences were observed in the 3D lateral canal obturation volume percentage at all three levels (P < 0.05). Both CWC and CLC techniques demonstrated higher 3D lateral canal obturation volume percentages (x ¯  = 89.64% andx ¯   =  73.28%; respectively) compared to the SC group)x ¯   =  43.10%).

CONCLUSION

BCHiF combined with the CWC technique has a higher ability to achieve preferable 3D obturation volume in the simulated lateral canal at 3, 5, and 7 mm.

CLINICAL RELEVANCE

In cases requiring endodontic treatment with lateral canals, the CWC obturation technique using BCHiF with gutta-percha may offer better outcomes compared to other obturation techniques.

Impact of the spatial orientation of the patient's head, metal artifact reduction, and tube current on cone-beam computed tomography artifact expression adjacent to a dental implant: A laboratory study using a simulated surgical guide

Purpose

The aim of this study was to evaluate image artifacts in the vicinity of dental implants in cone-beam computed tomography (CBCT) scans obtained with different spatial orientations, tube current levels, and metal artifact reduction algorithm (MAR) conditions.

Materials and Methods

One dental implant and 2 tubes filled with a radiopaque solution were placed in the posterior region of a mandible using a surgical guide to ensure parallel alignment. CBCT scans were acquired with the mandible in 2 spatial orientations in relation to the X-ray projection plane (standard and modified) at 3 tube current levels: 5, 8, and 11 mA. CBCT scans were repeated without the implant and were reconstructed with and without MAR. The mean voxel and noise values of each tube were obtained and compared using multi-way analysis of variance and the Tukey test (α=0.05).

Results

Mean voxel values were significantly higher and noise values were significantly lower in the modified orientation than in the standard orientation (P<0.05). MAR activation and tube current levels did not show significant differences in most cases of the modified spatial orientation and in the absence of the dental implant (P>0.05).

Conclusion

Modifying the spatial orientation of the head increased brightness and reduced spatial orientation noise in adjacent regions of a dental implant, with no influence from the tube current level and MAR.

GIRFT and Measuring Outcomes in MCNs: endodontics in 646 teeth treated in Tier 2 (Primary Care) and Tier 3 (Secondary Care) settings in England

AIM

This paper aims to assess the complexity, quality and outcome of endodontic treatment provided in Managed Clinical Networks (MCNs) in England to understand if we are "getting it right first time" (GIRFT).

METHODS

In a convenient sample of endodontic treatments provided between May 2011 and April 2017, the complexity of teeth treated, the quality of treatment procedure, the radiographic appearance of root fillings, as well as clinical and radiographic healing were retrospectively assessed using records taken as part of treatment. Trained, calibrated examiners independently scored radiographs using previously published scoring systems.

RESULTS

646 teeth were followed up for 24.7 months (standard deviation [SD] 17.08). The average age of those patients treated was 46.7 years (SD 15.38) with 48.3% being male. Of teeth treated, 70.4% were of complexity level 3. 88.2% of teeth were asymptomatic, and 80% demonstrated complete radiographic healing. Procedural errors inhibited achieving correct working length and taper, with more voids within root canal fillings. When patency filing was reported as being carried out, complete radiographic healing was more likely.

CONCLUSIONS

It is possible to collate outcome data in the NHS system, especially if there is provision for ongoing follow up and time allocated for collection of data. Endodontic treatment provided within primary and secondary care settings are of high quality, with outcomes being better with single operators carrying out high volumes of endodontic treatment.

Endodontic management of a maxillary first molar with three roots and six root canals

Variations in the root canal anatomy of a maxillary first molar are often challenging to diagnose and treat; thus, clinicians must have a thorough knowledge of the same. This case report highlights the successful nonsurgical endodontic management of a maxillary first molar with an unusual morphology of three roots and six root canals. A total of six root canals (mesiobuccal [MB] 1, MB2, MB3, distobuccal [DB] 1, DB2, and palatal) were detected after initiating root canal therapy and access cavity preparation. Conventional root canal treatment was completed, and postoperative cone-beam computed tomography scanning was done to verify the total number of canals and ensure the adequacy of root canal fillings. Managing such cases with rare variations in the root canal systems could be arduous and thus, clinicians should be well-versed in the methods to identify and manage such complexities to facilitate the successful outcomes of endodontic treatment.

Semi or fully automatic tooth segmentation in CBCT images: a review

Cone beam computed tomography (CBCT) is widely employed in modern dentistry, and tooth segmentation constitutes an integral part of the digital workflow based on these imaging data. Previous methodologies rely heavily on manual segmentation and are time-consuming and labor-intensive in clinical practice. Recently, with advancements in computer vision technology, scholars have conducted in-depth research, proposing various fast and accurate tooth segmentation methods. In this review, we review 55 articles in this field and discuss the effectiveness, advantages, and disadvantages of each approach. In addition to simple classification and discussion, this review aims to reveal how tooth segmentation methods can be improved by the application and refinement of existing image segmentation algorithms to solve problems such as irregular morphology and fuzzy boundaries of teeth. It is assumed that with the optimization of these methods, manual operation will be reduced, and greater accuracy and robustness in tooth segmentation will be achieved. Finally, we highlight the challenges that still exist in this field and provide prospects for future directions.

Cone-Beam Computed Tomography for the Evaluation of Dental Pulp Chamber Volume: Implications for Clinics and Teaching

The dental pulp chamber volume is a fundamental measurement in the field of endodontics, but also in forensic sciences, teaching and training, or tissue engineering. This study evaluates the precision of cone-beam computed tomography (CBCT) in comparison with computed micro-tomography (micro-CT) in evaluating the pulp chamber volume of the upper central incisors ex vivo. The intra-operator and inter-operator errors were evaluated, and the results for the two techniques were compared with those of a T-test for paired samples. The intra-operator and inter-operator errors were >0.05, indicating adequate reproducibility in each operator and no significant differences between their measurements. On the other hand, no significant differences between the two measurement techniques were found. The present results demonstrate that CBCT is a precise, feasible, and reproducible technique for the evaluation of the dental pulp chamber volume ex vivo. The results provided with this method are useful for different medical domains but also for the teaching and training of undergraduate and postgraduate students. Furthermore, the findings of this study carry significant clinical implications, as the accurate assessment of the pulp chamber volume is critical in the diagnosis and treatment of various endodontic conditions. The ability of CBCT to provide reliable 3D dental anatomy measurements can enhance the planning of endodontic treatments by allowing for a better understanding of the internal tooth morphology. Additionally, the precision and reproducibility of CBCT in assessing the pulp chamber volume can contribute to improved clinical outcomes and reduced complications during endodontic procedures. These findings further support the increasingly vital role of CBCT in modern clinical practice and underscore its value as an indispensable tool in the field of dentistry.

Prevalence and anatomic associations of middle mesial canals and isthmi in mandibular first molars: A CBCT-based study in a Northern Chinese population

This study investigated the prevalence of the middle mesial canal (MMC) and isthmus in a northern Chinese subpopulation using cone-beam computed tomography (CBCT). CBCT images of 1060 mandibular first molars (MFMs) were analysed. Data analysis was performed using the chi-square test, t-test, and multiple logistic regression analysis (p < 0.05). The prevalence of MMC and isthmus was 15.2% and 40.6%, respectively. The average dentinal thickness in the danger zone was 1.61 ± 0.14 mm. Patients younger than 40 years were two times more likely to have MMC (odds ratio [OR] = 2.204). Additionally, for every 1 mm reduction in the MB-ML orifice distance, the likelihood of detection of MMC in MFM nearly doubled (OR = 1.738). Furthermore, MFMs with MB-ML isthmus were five times more likely to exhibit MMC than those without it (OR = 4.756). The findings revealed that the prevalence of MMC and isthmus in MFMs is high and suggested that anatomical and demographic variables can serve as valuable indicators for clinicians in anticipating their presence.

Diagnostic value of cone beam computed tomography for root canal morphology assessment - a micro-CT based comparison

OBJECTIVES

The aim of this study was to assess cone beam computed tomography (CBCT) as a root canal anatomy diagnostic tool by comparison with micro-CT gold-standard.

MATERIALS AND METHODS

216 two-rooted mandibular molars were first scanned in a CBCT device (200 μm voxel size) and posteriorly in a micro-CT scanner (19.61 μm). The volumes were sequentially screened to classify main root canal anatomy according to Vertucci classification, and for the presence of lateral canals and apical deltas, in both mesial and distal roots.

RESULTS

Both methods revealed a higher prevalence of Vertucci Type II and IV in the mesial root, and Vertucci Type I in the distal root. The percentage of agreement for main root canal anatomy classification between CBCT and micro-CT scores was high (85.2%).

CONCLUSION

Sensibility to detect both lateral canals and apical deltas with CBCT was low. These results attest to the fact that minor anatomical changes might be difficult to identify with CBCT imaging, hampering its diagnostic value.

Periodontitis was associated with mesial concavity of the maxillary first premolar: a cross-sectional study

The association between the anatomical features of teeth and the pathogenesis of periodontitis is well-documented. This study aimed to evaluate the influence of the mesial concavity of the maxillary first premolar on periodontal clinical indices and alveolar bone resorption rates. Employing a cross-sectional design, in 226 patients with periodontitis, we used cone beam computed tomography(CBCT) to examine the mesial concavity and alveolar bone resorption of 343 maxillary first premolar. Periodontal clinical indicators recorded by periodontal probing in the mesial of the maxillary first premolar in patients with periodontitis. Our findings indicate that the presence of mesial concavity at the cemento-enamel junction of the maxillary first premolar was not significantly influenced by either tooth position or patient sex (p > 0.05). Nonetheless, the mesial concavity at the cemento-enamel junction of the maxillary first premolar was found to exacerbate alveolar bone resorption and the inflammatory condition (p < 0.05). We infer that the mesial concavity at the cemento-enamel junction of the maxillary first premolar may contribute to localized alveolar bone loss and accelerate the progression of periodontal disease.

Cone-beam computed tomography in endodontics: from the specific technical considerations of acquisition parameters and interpretation to advanced clinical applications

The implementation of imaging methods that enable sensitive and specific observation of anatomical structures has been a constant in the evolution of endodontic therapy. Cone-beam computed tomography (CBCT) enables 3-dimensional (3D) spatial anatomical navigation in the 3 volumetric planes (sagittal, coronal and axial) which translates into great accuracy for the identification of endodontic pathologies/conditions. CBCT interpretation consists of 2 main components: (i) the generation of specific tasks of the image and (ii) the subsequent interpretation report. A systematic and reproducible method to review CBCT scans can improve the accuracy of the interpretation process, translating into greater precision in terms of diagnosis and planning of endodontic clinical procedures. MEDLINE (PubMed), Web of Science, Google Scholar, Embase and Scopus were searched from inception to March 2023. This narrative review addresses the theoretical concepts, elements of interpretation and applications of the CBCT scan in endodontics. In addition, the contents and rationale for reporting 3D endodontic imaging are discussed.

Advances in medical image analysis with vision Transformers: A comprehensive review

The remarkable performance of the Transformer architecture in natural language processing has recently also triggered broad interest in Computer Vision. Among other merits, Transformers are witnessed as capable of learning long-range dependencies and spatial correlations, which is a clear advantage over convolutional neural networks (CNNs), which have been the de facto standard in Computer Vision problems so far. Thus, Transformers have become an integral part of modern medical image analysis. In this review, we provide an encyclopedic review of the applications of Transformers in medical imaging. Specifically, we present a systematic and thorough review of relevant recent Transformer literature for different medical image analysis tasks, including classification, segmentation, detection, registration, synthesis, and clinical report generation. For each of these applications, we investigate the novelty, strengths and weaknesses of the different proposed strategies and develop taxonomies highlighting key properties and contributions. Further, if applicable, we outline current benchmarks on different datasets. Finally, we summarize key challenges and discuss different future research directions. In addition, we have provided cited papers with their corresponding implementations in https://github.com/mindflow-institue/Awesome-Transformer.

Management of a permanent lateral incisor with a talon cusp and immature apex: A case report

This case report focuses on the diagnosis and treatment of a maxillary lateral incisor affected by a talon cusp, a rare developmental dental anomaly. The case presented with irreversible pulpitis and an immature apex. The article discusses the prevalence, etiology, classification, and treatment options for talon cusps, highlighting their clinical significance and potential complications. Clinical and radiographic findings obtained from a periapical radiograph and a cone-beam computed tomography (CBCT) scan are outlined. The treatment approach involved the removal of the talon cusp, endodontic therapy including apexification with mineral trioxide aggregate, and aesthetic restoration of the tooth. The report underscores the value of precise diagnosis, careful treatment planning, and the utility of CBCT scans in effectively managing talon cusps.

Cone-Beam Computed Tomography-Based Investigation of the Prevalence and Distribution of Pulp Stones and Their Relation to Local and Systemic Factors in the Makkah Population: A Cross-Sectional Study

Objectives This study aimed to assess the prevalence and distribution of dental pulp stones and evaluated their possible associations with local and systemic factors in the Makkah population in Saudi Arabia. Materials and methods Archived cone-beam computed tomography (CBCT) images for 390 patients, from the electronic health records (EHR) in the Dental Teaching Hospital, Umm Al-Qura University, were used. Images were examined in all planes (coronal, sagittal, and axial) for a discrete radiopaque mass in the pulp of all teeth, in both arches. The teeth conditions (the presence of caries, restoration, the periodontal condition, and the presence of pulp stones) were recorded. Additional patient information, including age, gender, and medical condition, was obtained from the patients' archived files. The collected data were statistically analyzed using the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY) software; a p-value of ≤ 0.05 is considered statistically significant. Results Pulp stone prevalence was 78.97% of the subjects (308 out of 390) and 15.92% of the examined teeth (1644 out of 10326). There were statistically significant differences regarding nationality (p=0.043) and age (p=0.023) but no significant difference between males and females (p=0.876), maxillary and mandibular teeth (p=0.392), and right and left sides (p=0.222) in pulp stone prevalence. Significant differences were found between pulp stone prevalence of sound versus and carious and restored teeth and between periodontally affected teeth and periodontally healthy teeth (p=0.031). Conclusion The prevalence of pulp stones in the Makkah population is high. A positive association was found between nationality, age, tooth restorations, caries, periodontal diseases, and pulp stone prevalence, but no correlation was found with patients' health or gender. The molars were the most affected teeth, while the incisors were the least.