|Year : 2015 | Volume
| Issue : 3 | Page : 97-103
Diagnostic accuracy of cone beam computed tomography in detection of simulated mandibular condyle erosions
Shahriar Shahab1, Nafiseh Nikkerdar2, Maryam Goodarzi3, Amin Golshah4, Sanaz Sharifi Shooshtari3
1 Department of Oral and Maxillofacial Radiology, School of Dentistry, Shahed University, Tehran, Iran
2 Department of Oral and Maxillofacial Radiology, Kermanshah University of Medical Sciences, Kermanshah, Iran
3 Department of Oral and Maxillofacial Radiology, School of Dentistry, Jundishapur University of Medical Sciences, Ahvaz, Iran
4 Department of Orthodontic, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
|Date of Web Publication||28-Aug-2015|
School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah
Source of Support: None, Conflict of Interest: None
Introduction: To determine the diagnostic accuracy of cone beam computed tomography (CBCT) in the detection of simulated mandibular condyle erosions.
Materials and Methods: Seventeen dry human mandibles were used in this in vitro study. NewTom VG CBCT scanner (New Tom VG, Verona, Veneto region, Italy) was used for the condyles imaging (pre-erosion and post-erosion image). Thirty three lesions were created on the superior (11 cases), anterior (11 cases), and posterior surfaces (11 cases) of the condyles. The pre- and post-erosion images were randomly presented to two previously calibrated oral and maxillofacial radiologists in order to evaluate the presence of simulated erosions and their position in the condyles using two protocols. In the first protocol, axial and coronal images and in the second protocol, axial, coronal, and sagittal/multiplanar reconstructed (MPR) images were used to evaluate the lesions of the samples. Furthermore, the Cochran's Q test and McNemar and Kappa statistical tests were used to assess the sensitivity, specificity, and accuracy of this study.
Results: There was no statistically significant difference between the diagnostic methods and the reference value. There was substantial agreement between the two protocols (Kappa > 0.61). Protocol 2 showed relatively better results than protocol 1 but the difference was not statistically significant (P > 0.05). Sensitivity, specificity, and diagnostic accuracy levels in the erosion imaging were higher in the posterior region of condyle; however, there was no statistically significant difference between the condylar regions (P > 0.05).
Conclusion: CBCT had high sensitivity, specificity, and diagnostic accuracy in the detection of simulated mandibular condyle erosions.
Keywords: Cone beam computed tomography (CBCT), erosion, mandibular condyle
|How to cite this article:|
Shahab S, Nikkerdar N, Goodarzi M, Golshah A, Shooshtari SS. Diagnostic accuracy of cone beam computed tomography in detection of simulated mandibular condyle erosions. Dent Hypotheses 2015;6:97-103
|How to cite this URL:|
Shahab S, Nikkerdar N, Goodarzi M, Golshah A, Shooshtari SS. Diagnostic accuracy of cone beam computed tomography in detection of simulated mandibular condyle erosions. Dent Hypotheses [serial online] 2015 [cited 2019 Sep 19];6:97-103. Available from: http://www.dentalhypotheses.com/text.asp?2015/6/3/97/163813
| Introduction|| |
Temporomandibular joint (TMJ) disorders (TMJ disorders = TMD) are a group of medical problems affecting the natural form and function of the jaw joint. TMD is the most common disorder of the jaw joint affecting 28-86% of adolescents and young adults.  Osteoarthritis is the most common pathological condition of TMJ caused by repetitive high impact force on this joint, which in turn destroys the articular cartilage and the subchondral bone. ,, Osteoarthritic bony changes include flattening, sclerosis, osteophytes formation, erosion and loss of condylar head, erosion of mandibular fossa, and reduced joint space.  Condyle erosion is the early stage of degenerative changes, which are indicative of the unstable condition of TMJ and the consecutive joint surface changes lead to changes in occlusion. 
Osteoarthritic bony change, including erosion, is one of the radiographic signs of this disease.  Two radiographic characteristics of different stages of osteoarthritis are joint surface erosions and osteophytes. Erosion is a localized area with decreased density of the condylar surface and adjacent cortical bone. 
Several studies have evaluated the radiographic views of TMJ. ,, Conventional radiographic scans cannot give accurate and precise information about the position of condyle and initial changes. , In a study that evaluated the efficacy of different imaging methods for the detection of condyle erosions, it was concluded that simple radiographic films could not efficiently detect and evaluate condylar erosions.  Panoramic radiography technique suffers from inherent distortion, reducing the diagnostic accuracy and reliability of this method for condylar erosion detection.
Two other investigators showed that panoramic imaging was weak in detecting the lesions [better receiver operating characteristic (ROC) values of type 0.68 and 0.54]. , Generally, panoramic imaging can only show wide erosions. Common tomography methods do not show the bony changes under 30% as these methods underestimate bone lesions and cannot show small lesions.
Diagnostic methods for TMJ imaging have been considerably developed in recent decades. Magnetic resonance imaging (MRI) is the gold standard for imaging of joint soft tissues.  However, in case of the three-dimensional (3D) images of the internal organs and bony structures of the body, computed tomography (CT) scan provides more useful information. Today, there are two main types of CT scans as follows: conventional CT and cone beam CT (CBCT).  CBCT was first introduced in dentomaxillofacial imaging in the late 1990s. 
CBCT can provide high-quality diagnostic images with submillimeter resolution, short scanning times and lower radiation dose compared to conventional CT. ,, These advantages will probably make CBCT the gold standard imaging technique for maxillofacial imaging.  Some studies have been conducted on the efficiency of CBCT for the detection of TMDs. , Other studies compared CBCT with conventional radiography, tomography, and multidetector CT (MDCT) in terms of its efficiency in the diagnosis of bone abnormalities. ,,, Although the results are promising, still more studies are required to evaluate the performance of different protocols of CBCT in TMJ imaging, especially in the detection of condylar defects. The present study was aimed to determine the sensitivity, specificity, and diagnostic accuracy of the two protocols of CBCT in evaluation of simulated erosion on different surfaces of mandibular condyle.
| Materials and Methods|| |
Over the course of this in vitro study, 17 dry human mandibles were used. The mandible condyles were intact and free from fracture. After local ethical approval. The visual examination of the condyles for the presence of pre-existing lesions was done and recorded for each area of condyles. To simulate the absorbing effect of soft tissue, the samples were separately put into dishes containing water, and subsequently, water covered the entire sample in all the cases. The mandibles were placed and fixed in the dishes similar to the patient's standing position. Then, a CBCT scanner (New Tom VG, Verona, Veneto region, Italy) scanned the samples using a 9-in detector field and automatic exposure parameters depending on bone volume and density. The scanner operated at 110 kV (constant), 5.6-11.40 mA, an exposure time of 3.6 s (constant), and voxel size 0.3 mm. The thickness of the image slices were 2 mm (fixed) and the distance between the slices was 0.5 mm for both lateral and frontal reconstructions. The NNT viewer software version 2.21 (New Tom, Verona, Veneto region, Italy) was used for the secondary image reconstruction process. In this study, lateral and frontal sections of the images were reconstructed perpendicular and parallel to the long axis of each condyle.
To simulate the erosion-induced lesions in the condyles, dental round bur (801 FG 010, Jota, Rüthi/SG, St. Gallen, Switzerland) mounted on a high-speed headpiece (TA-97 C, W&H, Büürmoos, Salzburg, Austria) was used. Totally, 33 lesions were created on the superior (11 cases), anterior (11 cases), and posterior surfaces (11 cases) of the condyles. They were randomly and equally distributed among the 33 condyles (one simulated erosion created in each condyle). One condyle was not used for simulated erosion. The width of simulated lesions was equal to the round bur diameter (1 mm) and their depth was half the bur diameter (0.5 mm). The lesions created in the condyles were then photographed by a digital camera (EOS 450d, Canon, OͿita, Japan) [Figure 1]. Pre-existing lesions and simulated erosions of each area of condyles were recorded as a reference for future assessments. In the next step, the mandibles were imaged with the same imaging parameters of the pre-erosion imaging process. These images were treated as post-erosion images for further assessment. The pre- and post-erosion images were randomly presented to two previously calibrated oral and maxillofacial radiologists who have 5 years of experience in evaluating CBCT images to evaluate the presence or absence of lesion and their position in the condyles using the two protocols. For calibration, the radiologists were asked to analyze two randomly selected condyles by CBCT. The results of identification and localization of the erosions were then evaluated and compared.
The images were presented by a 13.3-in monitor (LED flat screen, Sony, Minato, Japan) with a screen resolution of 1280 × 800 under identical illumination conditions [Figure 2] and [Figure 3]. In protocol 1, axial and coronal images and in protocol 2, axial, coronal, and sagittal/multiplanar reconstructed (MPR) images were used to evaluate the lesions of the samples. The survey was performed in two sessions with a 2-week interval. The lesions were categorized into anterior, posterior, and superior sites. The data obtained from these evaluations were collected in special information forms and then summarized and sorted in the interface tables. To evaluate the efficiency of the diagnostic methods, the results of each protocol were compared to the reference data. The collected data were analyzed using the statistical package of Statistical Package for the Social Sciences (SPSS) 16.0 (SPSS Inc., Chicago, IL, USA). All of the data were analytically and descriptively studied. The Cochran's Q test and McNamara and Kappa statistical tests were used to assess the sensitivity, specificity, and accuracy of this study. A significance level of 0.05 was set for all statistical analyses.
|Figure 2: An example of scanned sections before formation of lesions (pre-erosion image)|
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|Figure 3: An example of the scanned sections following the creation of lesions (post-erosion image)|
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| Results|| |
Sensitivity, specificity, positive and negative predictive values, and the accuracy of each protocol are shown in [Table 1].
|Table 1: Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and accuracy of each protocol in identification of simulated erosions |
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Cochran test showed that there was no difference between the diagnostic methods and reference. The comparison for the agreement between the obtained coefficients and gold standard based on the Kappa test for the observer 1-protocol 1, observer 1-protocol 2, observer 2-protocol 1, and observer 2-protocol 2 showed indices of 0.606, 0.667, 0.727 and 0.848, respectively. Based on the comparisons between the two observers using McNamara test in both protocols, there was no significant difference between the two protocols (P > 0.05). There was a substantial agreement between the two protocols (Kappa > 0.61) and there was no statistically significant difference between the two observers [Table 2].
|Table 2: Comparison between the observers and each protocol using the Kappa test |
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Sensitivity, specificity, and accuracy of both the protocols for superior, anterior, and posterior surfaces are shown in [Table 3]. Although protocol 2 had higher sensitivity, specificity, and accuracy than protocol 1, there was no statistically significant difference between the two protocols (P > 0.05). The maximum sensitivity, specificity, and accuracy values of protocol 1 in the diagnosis of simulated erosion were 90.9% (posterior surface), 86.35% (anterior and superior surfaces), and 88.3% (anterior surface), respectively. However, these values in protocol 2 were 90.9% (posterior surface), 95.45% (anterior and superior surfaces) and 90.85% (posterior surface) respectively.
|Table 3: Sensitivity, specificity, and accuracy of both the protocols for superior, anterior, and posterior surfaces of condyle |
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| Discussion|| |
CBCT provides multiplanar and 3D images of the condyle and the surrounding structures and facilitates the analysis of morphological characteristics of the bone, joint space, and dynamic performance. These are key factors in the provision of good treatment results to patients with TMDs.  The present study aimed to determine the diagnostic capability of CBCT in evaluating mandibular condyle erosion by two protocols (axial and coronal images, axial, coronal and sagittal/MPR images). The results showed high sensitivity, specificity, and accuracy of CBCT in detecting condyle erosion lesions in both protocols.
Honey compared the diagnostic accuracy of CBCT in TMJ imaging by panoramic and linear tomography.  Joint imaging was performed by corrected linear tomography (TOMO), panoramic -normal (Pan-N), and special panoramic (Pan-TM) TMJ and CBCT. Multiplanar CBCT images were exhibited statically (CBCT-S) and interactively (CBCT-I). Pan-N, CBCT-I, and CBCT-S were more reliable than TOMO. The diagnostic accuracy of CBCT-I and CBCT-S was higher than other methods. CBCT-I was more accurate than CBCT-S, and Pan-N was more accurate than Pan-TM and TOMO. The results of the study showed that CBCT images had higher diagnostic accuracy and reliability than TOMO and TMJ panoramic images in detecting condylar erosion. In comparison with the present study, the imaging was performed on TMJs of the cadavers and the size of lesions covered a big range. However, the present study merely evaluated the large size lesions.
Various studies have used CT to evaluate the TMJ pathological conditions, including Bayar and Choi, Moaddab, and Raustia. ,,, They found promising results regarding the use of CT in the analysis of TMJ pathologies. Goupille used coronal view CT and Hu applied axial view CT. , Cara et al. scanned 15 dry mandibles by single- and multislice slice CT scan.  In their study, the observers determined the presence and absence of bone lesions and their positions by four protocols (1. single-slice axial, 2. multi-slice axial, 3. single-slice MPR, and 4. multi-slice-axial/MPR). The lowest diagnostic accuracy was reported for single-slice axial protocol (62.7%) and the highest diagnostic accuracy was reported for multislice axial/MPR protocol (93.1%). In our study, the sensitivity of protocols was higher than the three other protocols and showed high efficiency of CBCT in the diagnosis of mandibular condyle erosion. It was less for protocol 4 since it used multislice CT/MPR that employed more doses compared to the CBCT. Unlike the current study, soft tissue absorbing effect was not used in this study.
Multiplanar view has more sensitivity than axial and coronal views. This variable has been shown in previous studies. , It should be noted that our study was performed in vitro with better accuracy compared to in vivo studies where the bone is surrounded by the tissues and it is possible to achieve low accuracy and specificity in clinical conditions.
In a study conducted on 3D CT, Kursunglu et al. showed that sagittal images of TMJ had good accuracy in evaluation of mandibular condyle and Glenoid fossa.  Other studies showed that sagittal and coronal images yielded valuable data in evaluation of TMJ. , Larheim et al. showed that multiplanar view had the highest accuracy in detecting bone changes, especially in diagnosis of rheumatoid arthritis. 
In this study, in line with the above studies, the accuracy levels of the multiplanar view (protocol 2) were 89.35% and 81.8% in axial and coronal views, respectively, (protocol 1). The results of this study were in agreement with the findings of Buckwatter et al. depicting more details in the volume data of the bones. 
The comparison of protocol 1 and protocol 2 showed no significant difference between these two protocols (P > 0.05). Although sensitivity, specificity, and accuracy values were high for protocol 2, it was because the erosions were observed in three different views. The statistical agreement between the two protocols was relatively substantial (Kappa > 0.61). There was no significant difference between the observers (P > 0.05). In line with other studies, in our study the multiplanar view had high sensitivity, specificity, and accuracy compared to axial and coronal views. The highest sensitivity was observed in the posterior surface of both protocols. The lowest sensitivity was observed in anterior and superior surfaces of protocol 1. These differences, however, were not significant (P > 0.05). It can be concluded that the sensitivity of CBCT was high for all joint surfaces regardless of the position of erosion. Other studies have mentioned high value and efficiency of CBCT in detecting lesions. , Honda et al. found that the accuracy and resolution levels of CBCT were high in investigating TMJ bone structure mainly due to the high accuracy of volumetric and isotropic data produced by CBCT. 
Marques et al. assessed the sensitivity and specificity of CBCT in simulated mandibular bone lesion.  They used the following two protocols for the assessment of each condyle:
In agreement with our study, findings of this study showed that there were no statistically significant differences between the two protocols although the MPR protocol shows slightly better results than the other protocol.
- Axial, coronal, and sagittal MPR and,
- Sagittal plus coronal slices throughout the longitudinal axis of mandibular condyles.
Ludlow compared coronal and sagittal images with multiplanar images and reported multiplanar protocol had high accuracy in detecting condylar bone erosions in an in vitro environment.  In this study, there was no significant difference between various regions of erosion on the condyles (P > 0.05). In the study performed by Ludlow, the results of different observers did not show a significant difference, the same as the present study.  This can be attributed to the fact that the observers were specialists in their field.
In a study conducted by Perrella et al., the diagnostic value, sensitivity, and specificity of single slice and multislice CT scans in the detection of mandibular lesions were reported to be 100%.  In this study, the size of the lesions was 3 mm, which was three times larger than the lesions created in our study. This difference in size explains the different results obtained.
In the study performed by Flygare et al., tomographic imaging method with axially corrected sagittal tomography was used.  Our study showed higher specificity in axial and coronal views (protocol 1) compared to the Flygare's study (90.55% vs 89%), the sensitivity in this study was 58% for condylar erosion but it was higher in our study. In our study, the sensitivity in detecting condylar erosion in axial and coronal views (protocol 1) was 81.85% and in condylar erosion in multiplanar view, it was 84.85% (protocol 2). The study of Flygare conducted on the TMJ of a corpse showed that CBCT had higher sensitivity and specificity than tomography to diagnose condylar erosions.
Hintze et al. compared CBCT and conventional tomography and found that conventional tomography with lateral view had a higher accuracy compared to CBCT with lateral view.  In the combination of frontal and lateral views, there was no difference between them and there was no significant difference in the diagnostic accuracy of these two methods to determine bony changes in condyle and articular tubercle (conventional tomograms and CBCT). The sensitivity of CBCT was higher in our study than that in Hintze's study. Salemi et al. compared the diagnostic accuracies of CBCT imaging to panoramic and spiral tomographic radiography for the detection of the simulated mandibular condyle lesion.  They concluded that the diagnostic accuracy of CBCT images was higher than that of spiral tomography and panoramic radiography. The accuracy, sensitivity, and specificity of CBCT of this study were similar to our study. However, we used more samples (33 condyles) than this study (10 condyles).
Comparing MRI and CT, Westesson et al. found that the CT sensitivity (100%) was higher compared to MRI sensitivity (50%).  CT sensitivity was higher in the study of Westesson compared to CBCT sensitivity in our study (100% vs 81.85% in protocol 1 and 84.85% in protocol 2). Westesson carried out a study on the existing lesions in the TMJ of a corpse with different size and form. Unlike our study, big-size lesions were not investigated. MRI sensitivity in the study of Wesesson was less than CBCT sensitivity in our study (75% vs 81.85% in protocol 1 and 84.85% in protocol 2). The specificity of MRI in the study of Westesson was 50%, while in our study the minimum specificity of CBCT in protocol 1 was 90.7%. According to this study, we can find about the high value of CBCT. Multiplanar protocol in CBCT had higher diagnostic accuracy than axial and coronal protocol, although this difference was not statistically significant. The sensitivity, specificity, and diagnostic accuracy of simulated erosions in posterior surface of condyle were higher than those of anterior and superior erosions although the difference was not statistically significant.
| Conclusion|| |
The findings of the current study showed that CBCT could show high sensitivity, specificity, and accuracy in the evaluation of simulated mandibular condyle erosion. Both protocols of CBCT (axial and coronal images, axial, coronal and sagittal/MPR images) were considered to be adequate in the detection of simulated condyle erosion in different surfaces, with the posterior surface showing slightly better results.
Financial support and sponsorship
The authors do not have any financial support.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]