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RESEARCH
Diagnostic accuracy of cone beam computed tomography and
conventional multislice spiral tomography in sheep mandibular
condyle fractures
Y Sirin*
,1
, K Guven
2
, S Horasan
3
and S Sencan
1
1
Department of Oral Surgery, Faculty of Dentistry and
2
Department of Radiology, Faculty of Medicine, Istanbul University,
Istanbul, Turkey;
3
Teknodent Oral and Maxillofacial Radiology Center, Istanbul, Turkey
Objectives: The aim of this study was to compare diagnostic accuracy of cone beam CT
(CBCT) and multislice CT in artificially created fractures of the sheep mandibular condyle.
Methods: 63 full-thickness sheep heads were used in this study. Two surgeons created the
fractures, which were either displaced or non-displaced. CBCT images were acquired by the
NewTom 3G
H
CBCT scanner (NIM, Verona, Italy) and CT imaging was performed using the
Toshiba Aquillon
H
multislice CT scanner (Toshiba Medical Systems, Otawara, Japan). Two-
dimensional (2D) cross-sectional images and three-dimensional (3D) reconstructions were
evaluated by two observers who were asked to determine the presence or absence of fracture
and displacement, the type of fracture, anatomical localization and type of displacement. The
naked-eye inspection during surgery served as the gold standard. Inter- and intra-observer
agreements were calculated with weighted kappa statistics. The receiver operating
characteristics (ROC) curve analyses were used to compare statistically the area under the
curve (AUC) of both imaging modalities.
Results: Kappa coefficients of intra- and interobserver agreement scores varied between
0.56 – 0.98, which were classified as moderate and excellent, respectively. There was no
statistically significant difference between the imaging modalities, which were both sensitive
and specific for the diagnosis of sheep condylar fractures.
Conclusions: This study confirms that CBCT is similar to CT in the diagnosis of different
types of experimentally created sheep condylar fractures and can provide a cost- and dose-
effective diagnostic option.
Dentomaxillofacial Radiology (2010) 39, 336–342. doi: 10.1259/dmfr/29930707
Keywords: cone beam computed tomography; multislice computed tomography; condyle;
fracture; sheep
Introduction
Following two consensus meetings
1,2
in which research-
ers have had only limited agreement on an optimal
treatment strategy in adults
3
subject to more than six
classification proposals in the past 80 years,
4
the
treatment of mandibular condyle fractures still remains
a controversial topic in maxillofacial traumatology.
5
Mandibular condyle fractures account for 17.5 – 52%
of all mandibular fractures.
6
80%of the cases are
unilateral, occurring mainly between the ages of 20 to
39 years and the male to female ratio is 3:1.
7
These
fractures are mostly caused by indirect forces trans-
mitted from a distant point to the condylar area.
Consequently, these fractures are prone to misdiagno-
sis.
6,8
Common clinical signs include bone deflections,
difficulty in opening the mouth, malocclusion, oedema
and swelling in the peripheral region of the external
acoustic meatus.
9
Conservative approaches with bimax-
illary fixation or open reduction with internal fixation
are the main treatment options for condylar fractures.
To decide between these two treatment modalities it is
essential to analyse variables, such as maximum mouth
opening, protrusion, tendency for scarring and the
imaging characteristics of the fracture localization.
10
*Correspondence to: Dr Yigit Sirin, Istanbul Universitesi, Dishekimligi
Fakultesi, Agiz-Dis Cene Hast. Ve Cerr. Anabilim Dali 34390 Capa/Fatih/
Istanbul, Turkey; E-mail: ysirin@istanbul.edu.tr
Received 14 July 2009; revised 1 September 2009; accepted 14 September 2009
Dentomaxillofacial Radiology (2010) 39, 336–342
’2010 The British Institute of Radiology
http://dmfr.birjournals.org
The accurate diagnosis of mandibular condyle fractures
requires a thorough radiographic examination. Conven-
tional plain radiography may result in images with
superimpositions of the adjacent tissues and overlapping
of bony structures, which often makes the interpretation
difficult, especially in sagittal and intracapsular fractures.
2
This is a significant disadvantage in the imaging of high
condylar fractures because the treatment outcome
depends on the position of the fracture line, the
comminution of the proximal fragments and the short-
ening of the mandibular ramus.
11
On the other hand,
cross-sectional tomography has been shown to have an
accuracy of 87.5–96%in revealing structural changes of
temporomandibular joint (TMJ).
12
As a result, the
introduction of modern CT has allowed the TMJ to be
clearly visualized without the interference of nearby
anatomical structures. However, the conventional CT
concept has been criticized for the high radiation doses
used, the high cost, the large space requirements and the
high level of skill needed for interpretation.
13–16
Cone
beam CT (CBCT) has been introduced to overcome these
limitations in the imaging of craniofacial structures. This
technique uses a cone-shaped X-ray beam, in contrast to
the fan-shaped X-ray beam of spiral CT. The object to be
evaluated is captured as the radiation source falls onto a
two-dimensional (2D) detector, allowing the single,
rotation of the radiation source to capture the entire
region of interest (ROI).
17
This cost-efficient imaging
modality has been used by a broad range of specialties
including orthodontics, implantology and oral surgery.
18
It has been found to be successful in producing multi-
planar images of the dental structures and the TMJ with
lower radiation doses, achieving a higher spatial resolu-
tion owing to its limited exposure field.
18–20
CBCT and CT have been tested separately under
different clinical and experimental conditions for the
imaging of TMJ bone structures;
20
however, no study
has compared the diagnostic accuracy of these two
imaging modalities in maxillofacial fractures. There-
fore, the purpose of this paper is to evaluate CBCT and
CT imaging techniques in experimentally created
fractures of the sheep mandibular condyle.
Materials and methods
63 fresh sheep heads bred for human consumption and
purchased from a local butcher shop were used in this
study. All left and right TMJ regions were numbered
consecutively using permanent marker pens. Odd
numbers were assigned to the left TMJ of animals
whereas even numbers represented the right side.
Maxillo-mandibular fixation was achieved using soft
ligature wires (RemaniumH; Dentaurum Group,
Ispringen, Germany). Two surgeons (YS and SS)
performed the procedures and registered the type of
fractures created; this information was not made
available to the other researchers. The naked-eye
inspection served, therefore, as the gold standard for
the radiographic examinations. A modified version of
the method described by Long and Goss
21
was used.
Following a pre-auricular incision, the TMJ capsule was
exposed and cleared of soft tissues by a blunt dissection,
and the inferior joint space was opened by a horizontal
incision through the capsule at the condylar neck. The
condylar head was isolated with a periosteal elevator,
and the superior joint space was exposed by separating
the lateral attachment of the disc through the inferior
joint space. The anterior and posterior attachments of
the disc were cut. Some of the condyles were left intact
and served as sham-operated joints. The fractures were
planned to be either displaced (medial, lateral, anterior
and posterior displacements) or non-displaced (com-
plete, incomplete or comminuted) (Figures 1–6).
Experimental groups were distributed unevenly in order
to prevent the observers from estimating the exact
number of fractures in the groups (Figure 7). A 0.9 mm
diameter straight fissure diamond burr with a long shaft
mounted on a high-speed dental hand piece was used to
create a deep crack in the direction of the planned
fracture under constant irrigation and suction to prevent
scattering of bony particles into the soft tissues. A
periosteal elevator was inserted into the prepared gap
and turned around itself until the condylar fragment was
separated from the ramus. The proximal bone segment
was then repositioned to the pre-determined location
using pliers to simulate the displacement or was left in
place for non-displaced but complete fractures. For the
fissure-type fracture, the condylar segment was not
completely separated. Small parallel cuts in the hor-
izontal and vertical directions were prepared and
cracked through the condylar surface for the commin-
uted type of fracture. All fractures were stabilized in
position using cyanoacrylate-containing universal
instant adhesive (Pattex
H
; Henkel Gmbh., Istanbul,
Turkey) and photographed. Surgical wounds were then
closed with 5.0 silk sutures. The sheep heads were seated
on a custom-made adjustable transparent plastic tem-
plate and fixed for radiographic analysis.
Conventional multislice spiral tomography
The sheep heads were scanned with a Toshiba Aquilion
64-slice scanner
H
(Toshiba Medical Systems, Otawara,
Japan). After obtaining anterior–posterior and lateral
scouts, the field of view (FOV) was decided at the table,
as the sizes of the heads were different from each other,
ranging from 24 to 32 cm. The scanning parameters were
as follows: 0.5 mm collimation, 0.5 s gantry rotation
time, 1.0 pitch, 120 kV and 175 mAs, acquisition time 9–
15 s with volumetric data acquisition enabled. The
images were reconstructed at 0.5 mm intervals in 64
slices without any interslice gaps using both head and
bone tissue filters. The reconstructed images were
transferred to the workstation using Vitrea 2 software
H
,
version 4.1 (Vital Images Inc., Minnetonka, MN). The
reconstructed images were analysed by standardized
0.5 mm slice thickness, 0.5 mm reconstruction interval
in axial, coronal and sagittal multiplanar reformatted
CBCT and CT in sheep condylar fractures
Y Sirin
et al
337
Dentomaxillofacial Radiology
(MPR) views, and 3D views. Window levels were set to
W 3000 and L 800, and a 23 inch Apple
H
high-definition
display monitor (Apple Inc., Cupertino, CA) was used
for image evaluation.
Cone beam CT
All sheep heads were scanned using the NewTom 3G
H
CBCT scanner (NIM, Verona, Italy) with a 9 inch
detector field and automatic exposure parameters. The
scanner operates with a maximum output of 110 kV
and 15 mAs. Average scan time is 36 s and typical
exposure time is 5.4 s. Safe Beam
H
and Smart Beam
H
technologies used in CBCT automatically adjust the
radiation dose based on the patient size. Therefore,
these exposure parameters were different for each sheep
head. Specimens were placed in the supine position in
the scanner’s gantry by aligning the mid-sagittal plane
of the sheep head to the scanner’s medial light beam,
and the lateral light spot was centred at the level of
the condyle, indicating the optimized centre of the
reconstruction area. The position of the specimen was
checked and small adjustments were made according to
frontal and lateral scout views. Scanning was per-
formed by a single 360˚rotation of the X-ray tube-
detector system around the sheep heads. The CT data
were imported into the NewTom 3GHsoftware for the
reconstruction of images. Post-processing was applied
to the initial raw data by selecting a small field, high
resolution and 0.5 mm of axial slice. A new FOV was
formed with 240 axial cuts, and secondary reconstruc-
tion was performal to produce MPR images. Axial,
coronal and sagittal images with 0.5 mm slice thickness
and 0.5 mm reconstruction interval were displayed on a
23 inch Philips
H
(Royal Philips Electronics Inc.,
Amsterdam, the Netherlands) LCD monitor. The
density and the contrast of the images were adjusted
to a standard bone window and level (W/L 3000/800,
respectively). The sheep heads were treated as medical
Figure 1 Three-dimensional CT view of an anterior condyle
displacement
Figure 2 Axial CT and cone beam CT views of bilateral condyle
fractures with displacement. Right side (R): medial displacement, left
side (L): lateral displacement
Figure 4 Three-dimensional reconstruction of a posteriorly dis-
placed condyle fracture in cone beam CT
Figure 3 Oblique CT view of a comminuted fracture (left) and a
sham operated condyle (right)
CBCT and CT in sheep condylar fractures
338 Y Sirin
et al
Dentomaxillofacial Radiology
waste and were disposed of in red bags as soon as the
radiographs were taken.
A pre-calibration session was conducted to familiar-
ize the two observers with the sheep head anatomy.
Observer 1 (KG) was a general radiologist working in
the head and neck region and observer 2 (SH) was an
oral and maxillofacial radiologist. Both observers had
over 5 years of experience with TMJ evaluation. They
independently assessed left and right joints with both
imaging modalities in different sessions in a randomized
order for presence (1) or absence (0) of fracture and
presence (1) or absence (0) of displacement. Whenever a
displacement was detected, the observers were asked to
describe the type of displacement (1, medial; 2, lateral;
3, anterior; 4, posterior) and in the case of a non-
displaced, but fractured, condyle they had to decide the
presence (1) or the absence (0) of either one of the
fissure, comminuted or complete types of fractures. The
TMJ regions labelled with odd numbers were assessed a
second time after 3 weeks using the same procedures
with both radiographic modalities to evaluate intra-
observer reproducibility.
Statistical analysis
Data were analysed using MedCalc 7.2 statistical
software
H
(MedCalc Inc., Mariakerke, Belgium). The
weighted kappa values were calculated to measure intra-
and interobserver variability and to assess the level of
agreement between these values and the gold standard.
These results were interpreted according to the criteria of
Landis and Koch:
22
0.81 (very good or excellent), 0.61–
0.80 (good or substantial), 0.41–0.60 (moderate), 0.21–
0.40 (fair) and 0.20 (poor) agreement. The diagnostic
accuracies of the imaging modalities were compared with
the gold standard by calculating the percentage of
sensitivity and specificity values which were presented
as receiver operating characteristics (ROC) curve areas.
The area under the curve (AUC) was statistically
compared in a confidence interval of 95%, and the
results were considered significant when the P-value was
less than or equal to 0.05.
Results
One sheep’s head already had a posteriorly displaced
bone fragment in the condylar area and a mandibular
angle fracture, which was probably due to transporta-
tion. This case was also included in the study. The
kappa values for intra-observer agreement of observer 1
varied between 0.56 and 0.92 (moderate to excellent) for
CT and between 0.64 and 0.92 (good to excellent) for
CBCT. Observer 2 had similar scores for both imaging
modalities, 0.57–0.92 for CT and 0.79–0.92 for CBCT.
The kappa values for the two observers revealed good
to excellent agreement for CT and CBCT (0.62–0.98
and 0.60–0.97, respectively). The complete and com-
minuted fractures had the lowest agreement scores
between the observers, although these differences were
not statistically significant. Both tomographic devices
were found to produce reliable images as the kappa
values obtained in comparison with the gold standard
were 0.69–0.97 for CT and 0.68–0.96 for CBCT.
Furthermore, CT and CBCT were in good to excellent
agreement as the kappa values were 0.64–0.94 for the
interpretation of the reconstructed images. There was
no difference in the diagnostic accuracies of CT and
Figure 5 Cone beam CT of bilateral fractured condyles from the
coronal plane. Medial displacement on the left and a fracture without
displacement on the right side are clearly visible
Figure 6 Cone beam CT imaging from the sagittal plane, note the
posterior displacement of the condyle fracture
CBCT and CT in sheep condylar fractures
Y Sirin
et al
339
Dentomaxillofacial Radiology
CBCT with respect to the variables examined, as the
comparison of AUCs revealed no statistically signifi-
cant results (Table 1).
Discussion
The selection criteria for an imaging modality suggest
that a radiographic examination can contribute to the
proper diagnosis and care of the patient.
23
Radiographic
analysis has long been considered an integral part of
TMJ examination, which is often necessary for the
treatment of diseases and conditions compromising the
integrity of this region.
24,25
Panoramic radiographs,
transcranial projections and conventional tomography
have been found to have limited accuracy in the imaging
of TMJ,
23,26,27
whereas MRI is thought to provide more
information than any other imaging modality, especially
for the soft tissue components of the joint.
28,29
This
option might be technically considered optimal for TMJ
imaging; however, from a practical point of view, CT is
the most useful imaging modality in the diagnosis of
disorders affecting the bony components of TMJ.
Complex anatomical structures surrounding the joint
require high-quality cross-sectional and multiplanar
views, particularly in the cases of condylar fractures
which usually contain small bone fragments.
30,23,29
To
compare the accuracy of CT and CBCT, both of which
are capable of producing such detailed images, an in vivo
study model was used and modified by adding different
types of fractures from in vivo experimental work
21
on
the healing of intracapsular condylar fracture in sheep.
The results showed good correlation in intra- and extra-
observer scores and were generally in good agreement
with the gold standard.
Conventional CT has been used largely for the
assessment of TMJ pathology.
9,20,23,31
In earlier studies,
Westesson et al
32
compared the effectiveness of CT with
MRI in detecting bone and soft tissue changes of the
autopsy specimens and suggested that CT was superior
to MRI in showing osseous abnormalities, whereas
Tanitomo et al,
33
who examined the diagnostic yield of
the structural changes on TMJ, concluded that the
temporal component is better visualized by axially
corrected tomography than CT. However, these early
results must be approached with caution as these studies
probably do not reflect the true potential of today’s CT
technology. Accordingly, Katsumata et al
34
found good
agreement between CT and MRI in the remodelling of
the condyle following mandibular setback osteotomy for
prognatism. Cara et al
35
tested the validity of single-slice
and multislice CT for the detection of simulated condyle
lesions on dry mandibles using different observation
protocols. They reported that the best results for
mandibular condyle assessment were obtained by using
multislice CT with an axial/MPR protocol and corre-
lated these findings with the extended anatomical
coverage of TMJ using thinner slices. They also pointed
out that these values could be changed owing to the
Figure 7 Schematic presentation of the condylar fracture types and the distribution of experimental groups. TMJ, temporomandibular joint
Table 1 Statistical comparison of the area under the curve values for diagnostic accuracy of imaging modalities
CT Cone beam CT CT/Cone beam CT
AUC ¡SE AUC ¡SE Difference between areas P-value
Presence of fracture 0.997 ¡0.002 0.995 ¡0.003 0.002 0.664
Presence of displacement 0.923 ¡0.014 0.931 ¡0.014 0.008 0.582
Type of displacement 0.709 ¡0.042 0.799 ¡0.042 0.009 0.772
Fissure fracture 0.949 ¡0.023 0.882 ¡0.034 0.067 0.076
Comminuted fracture 0.846 ¡0.036 0.891 ¡0.031 0.044 0.278
Non-displaced complete fracture 0.902 ¡0.032 0.887 ¡0.034 0.015 0.721
AUC, area under the curve; SE, standard error
CBCT and CT in sheep condylar fractures
340 Y Sirin
et al
Dentomaxillofacial Radiology
attenuation of radiographs if there were soft tissues
surrounding the joint. This approach was one of the
reasons a full-thickness model was chosen for this study
and similar equipment and protocols were used in
detecting condylar fractures. The present results also
support the use of the axial/MPR approach in the
imaging of condylar fractures. Additionally, within the
limits of this study, it is thought that existing soft tissues
did not hamper the diagnostic capacity of CT for any
type of fractures examined, as there was good agreement
between this imaging modality and the gold standard.
Costa e Silva et al
30
evaluated the validity of 2D and 3D
CT in condylar fractures of 18 patients, considering
surgery as the gold standard. They concluded that the
two reconstruction procedures presented similar diag-
nostic validity. They also noted that the 3D CT
technique provided an improvement in the anatomical
localization of the fracture and in the sensitivity of
detecting comminution and bone displacements. The
present study also used 3D techniques as a supplemen-
tary viewing process not only for diagnosis, but to
confirm the position of the fractures.
Although CBCT is a relatively new concept in
maxillofacial radiology, it has already been used
specifically on TMJ imaging.
19
Recently, Ikeda and
Kawamura
36
used limited CBCT to assess optimal
condylar position. Furthermore, Alexiou et al
37
eval-
uated the severity of TMJ osteoarthritis changes using
CBCT and correlated these deformations with age.
Cevidanes et al
38
also used this modality to compare
displacement of the condyle inside the glenoid fossa
following orthognatic surgery using superimposition of
3D models constructed from CBCT. Similarly,
Schlueeter et al
16
examined optimal window levels
and width needed for condyle examination on 3D
reconstructions from CBCT. They suggested that the
soft tissue will reduce the observer’s capacity to view
bone topography, and 3D reconstructed images may
not be a reliable way to diagnose condylar pathology
and morphology. Considering the fractures as lesions
on the condyle, the present findings with CBCT reveal
that this modality was able to produce results consistent
with the naked-eye inspection when examined by both
observers. 3D reconstructions were used as an adjunct
to multiplanar examination of condylar fractures.
As this was the first in vitro study comparing the
diagnostic accuracy of CT and CBCT in experimentally
created condylar fractures, there are no previous articles
that can be directly related to the results. However, these
imaging modalities have previously been used to examine
the TMJ in different experimental settings. Honda et al
15
examined helical CT and CBCT in the detection of
mandibular condyle osseous abnormalities on autopsy
specimens. They found good agreement between the
imaging modalities and macroscopic observations con-
cerning normal cortical bone, condylar osteophytosis and
condylar erosion. On the other hand, Hintze et al
39
compared the reliability of CBCT and conventional
tomography using the Cranex-Tome
H
unit detecting
morphological changes of the condyle in dry skulls,
described as flattening, defects and osteophytes. They
observed low sensitivity, but high specificity for various
types of changes, and they also stated that conventional
spiral tomography showed a significantly higher specificity
than CBCT, but only for the detection of defects on frontal
views. Moreover, they reported large, but non-significant,
observer variations in the assessment of condylar changes
with conventional tomography for the detection of bone
defects, and correlated these results with the particular
difficulty arising from identifying these defects. Honey et
al
40
used a similar study design focusing on condylar
erosion in which they compared the diagnostic reliability of
CBCT, TMJ panoramic projections and corrected angle
linear tomography. They obtained substantially greater
intra-observer agreement than with plane projection linear
tomography and higher diagnostic accuracy with CBCT
than with other imaging modalities. The present findings
show a mostly good level of agreement between the
observers on the imaging modalities and the gold standard.
Furthermore, no difference in the diagnostic accuracy of
any imaging modality was observed with the experimental
settings. The differences between our results and those of
the aforementioned studies are probably related to the wide
range of equipment and imaging protocols which were
used. To overcome this predictable inconsistency, which is
also a limitation in this study, the use of high-end devices
was preferred, and the set-up of sophisticated observational
standards by equalizing data acquisition and processing
was used as far as possible within the limits of dif-
ferent hardware and software structures of the imaging
modalities.
In conclusion, the accuracy of CBCT, which is a
relatively new concept in maxillofacial radiology, is
similar to that of CT in the diagnosis of different types
of experimentally created sheep condylar fractures.
Furthermore, CBCT is significantly cheaper and it uses
a considerably lower radiation doses than conventional
CT. From this point of view, CBCT provides a cost-
and dose-effective alternative diagnostic method in
maxillofacial imaging.
Acknowledgments
This work was supported by a Research Fund of the Istanbul
University, project number, UDP-3786/22052009. This article
has been partially presented as a poster in the 17th
International Congress of Dentomaxillofacial Radiology, 28
June – 2 July 2009, Amsterdam, the Netherlands.
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