2D Versus 3D Radiographs in the Localization of Upper Impacted Canines

Evaluation of the Diagnostic Accuracy of Cone-beam Computed Tomography (CBCT) Imaging Compared to the Two-dimensional (2D) Methods in the 3D Localization and Assessment of Maxillary Impacted Canines: A Surgical-exposure-based Study

Seventeen patients diagnosed with the extraction-based treatment of impacted maxillary canines will be included in this study. Each patient will undergo conventional 2D radiography including panoramic, and lateral cephalometric, in addition to 3D imaging by cone beam computed tomography (CBCT) images.

A set of variables will be evaluated on 2D and 3D images by a panel of assessors and then these results will be compared with the gold standard which will be established based on surgical detection and direct visualization of the impacted canine.

Study Overview

• Status: Completed
• Conditions: Impacted Canines
• Intervention / Treatment: Other: Panoramic and lateral cephalometric radiography; Other: Cone beam computed tomography; Other: Surgery

Detailed Description

After taking the radiographic records, the impacted maxillary canines will be surgically exposed under local anesthesia where a full-thickness flap will be elevated from the buccal or palatal according to the initial radiographic diagnosis.

After cleaning the work yard to achieve good visibility, the pre-extraction parameters will be recorded which will be included labiopalatal position, mesiodistal position, and vertical position of the canine cusp, in addition to ankyloses of the impacted maxillary canine, proximity to the adjacent teeth, resorption of the adjacent incisors induced by the impacted maxillary canine, and bony coverage of the canine crown.

This will be followed by the extraction of the upper impacted canine and the recording of the post-extraction parameters, which will include the shape and the root apex development of the extracted canine. The pre- and post-extraction readings will be deemed the gold standard which will be compared to the 2D- and 3D-based assessments of the assessors.

Assessment sessions will be divided into two sessions with a one-week break in between. The first session will be devoted to the evaluation of the 2D image sets, while the second one will be to the evaluation of the 3D images.

Before beginning the assessment, the assessors will be subjected to a set of instructions and clarifications, including a set of graphs that help each assessor to accurately identify each variable, in addition to an oral explanation of some points so that the assessor will not fall into doubt when evaluating the radiographs.

• Study Type: Observational
• Enrollment (Actual): 17

Contacts and Locations

Study Locations

• Syrian Arab Republic
  • Damascus, Syrian Arab Republic
    • Department of Oral and Maxillofacial Surgery, University of Damascus Faculty of Dentistry

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 27 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Patients with impacted canines. These canines should be located unilaterally. The orthodontic decision should include the removal of these impacted canines in the course of orthodontic treatment.

Description

Inclusion Criteria:

1. Patients from both gender (Male and female), Age range: 14-27 years.
2. Unilateral impaction of the maxillary canines requiring surgical extraction.
3. Non-syndromic patients without any pathology of the maxillofacial region (benign or malignant tumor, cleft lip or cleft palate, trauma)
4. Patients with a set of panoramic and lateral cephalometric images, in addition to CBCT radiograph (CBCT is indicated for treatment planning)
5. The time period between taking the radiological records and undergoing the surgical intervention does not exceed four weeks

Exclusion Criteria:

1. Patients who had a systemic disorder, cleft lip/cleft palate, craniofacial syndrome, traumatic injury, and congenital number anomaly.
2. Patients had previous orthodontic treatment.

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Canines assessed using 2D images; The 2D-based assessments of the impacted maxillary canine.	Other: Panoramic and lateral cephalometric radiography; The 2D-based assessments of the impacted maxillary canine will be achieved using panoramic and lateral cephalometric radiographs.
Canines assessed using 3D images; The 3D-based assessments of the impacted maxillary canine.	Other: Cone beam computed tomography; The 3D-based assessments of the impacted maxillary canine will be achieved using a cone beam computed tomography (CBCT) image.
Canines assessed intra-operatively or post-operatively; The gold standard-based assessments are based on surgical exposure.	Other: Surgery; The surgical exposure will be accomplished, and the impacted maxillary canine will be assessed by a direct vision.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Labiopalatal position of the canine cusp	Assessment will be performed relative to the adjacent teeth based on classification into three categories: 1-Labial, 2-In situ, 3- Palatal	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
Mesiodistal position of the canine cusp	Assessment will be performed based on classification into five sectors: Section (B') From the distal margin of the central incisor to the midline of the Palatine. Section (B) Between the mesial and distal margins of the lateral incisor on the same side of the impaction. Section (A) Between the distal of the lateral incisor and the mesial of the 1st premolar on the same side of the impaction. Section (C) Between the mesial and distal margins of the 1st premolar on the same side of the impaction. Section (C') Between the distal of the 1st premolar and the distal of the 2nd premolar.	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
The vertical position of the canine cusp	Assessment will be performed based on classification into three categories: 1-The cervical third, 2-The middle third, 3-The apical third	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
Ankylosis of the impacted maxillary canine	Assessment will be performed based on periodontal ligament distance (the canine root will be considered ankylosis if the periodontal ligament distance is equal to zero)	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
Proximity to the adjacent teeth	Assessment will be performed based on contact with the root of the adjacent incisor (the canine will be considered in contact when the space by 0 mm or less than 0.5 mm)	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
Resorption of the adjacent incisors induced by the impacted canine	Assessment will be performed based on the presence or absence of resorption in the adjacent teeth.	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
Bony coverage of the impacted maxillary canine	Assessment will be performed based on the classification of the bony coverage amount of the impacted canine crown into: 1- Completely covered with bone, 2- Partially covered with bone, 3- Uncovered	The assessment will be performed after the surgical exposure of the impacted maxillary canine and "during surgery", i.e., after 10 minutes of the surgical exposure.
The shape of the extracted canine	Assessment will be performed based on the angle between the long axis of both the root and the crown and it will be classified into: 1-Straight (0°-10°), 2-Mildly curved (10°-30°), 3-Severe curved (>30°)	The assessment will be performed after the extraction of the impacted maxillary canine, i.e., immediately following surgery
Root apex closure of the extracted canine	Assessment will be performed based on classification into two categories: 1-Open apex, 2- Closed apex	The assessment will be performed after the extraction of the impacted maxillary canine, i.e., immediately following surgery
Diagnostic accuracy, sensitivity, and specificity	Values of the parameters were assessed using CBCT and 2D radiographs.	The assessment will be performed after the extraction of the impacted maxillary canine, i.e., immediately following surgery

Collaborators and Investigators

• Sponsor: Damascus University
• Investigators: Study Director: Mohammad Y. Hajeer, DDS MSc PhD, Department of orthodontics, Damascus University, Syria; Principal Investigator: Ayman Shaweesh, DDS MSc, Department of Oral and Maxillofacial Surgery, Damascus University, Syria; Study Chair: Bassel Brad, DDS MSc PhD, Department of Oral and Maxillofacial Surgery, Damascus University, Syria

Publications and helpful links

General Publications

• Walker L, Enciso R, Mah J. Three-dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2005 Oct;128(4):418-23. doi: 10.1016/j.ajodo.2004.04.033.
• Alqerban A, Storms AS, Voet M, Fieuws S, Willems G. Early prediction of maxillary canine impaction. Dentomaxillofac Radiol. 2016;45(3):20150232. doi: 10.1259/dmfr.20150232. Epub 2015 Dec 18.
• Al-Homsi HK, Hajeer MY. An Evaluation of Inter- and Intraobserver Reliability of Cone-beam Computed Tomography- and Two Dimensional-based Interpretations of Maxillary Canine Impactions using a Panel of Orthodontically Trained Observers. J Contemp Dent Pract. 2015 Aug 1;16(8):648-56. doi: 10.5005/jp-journals-10024-1736.
• Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two- versus three-dimensional imaging in subjects with unerupted maxillary canines. Eur J Orthod. 2011 Aug;33(4):344-9. doi: 10.1093/ejo/cjq102. Epub 2010 Dec 3.
• Hajeer MY, Al-Homsi HK, Alfailany DT, Murad RMT. Evaluation of the diagnostic accuracy of CBCT-based interpretations of maxillary impacted canines compared to those of conventional radiography: An in vitro study. Int Orthod. 2022 Jun;20(2):100639. doi: 10.1016/j.ortho.2022.100639. Epub 2022 May 21.

Study record dates

Study Major Dates

• Study Start (Actual): January 20, 2016
• Primary Completion (Actual): December 12, 2016
• Study Completion (Actual): August 5, 2018

Study Registration Dates

• First Submitted: February 13, 2023
• First Submitted That Met QC Criteria: February 23, 2023
• First Posted (Estimate): February 27, 2023

Study Record Updates

• Last Update Posted (Estimate): February 27, 2023
• Last Update Submitted That Met QC Criteria: February 23, 2023
• Last Verified: February 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Stomatognathic Diseases; Tooth Diseases; Tooth, Impacted
• Other Study ID Numbers: UDDS-Ortho-01-2023

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No