BASIC RESEARCH – TECHNOLOGY

Carlos Boveda, Od, Endod, Esp

Pericervical Dentin Metrics in Endod, PhD,* Anil Kishen, BDS,
MDS, PhD,†‡ Beatriz Millan, Od,
Mandibular First Molars Esp Endod, PhD,*
María V. Camejo, Od, Esp
Determined with Digital Endod, PhD,* and
Jose Francisco Gomez-Sosa,
Periapical Radiography and DDS, PhD*

Cone-beam Computed
Tomography

ABSTRACT
SIGNIFICANCE
Introduction: Pericervical root dentin is decisive for the long-term mechanical integrity of
root-filled teeth. Current treatment protocol does not include a customized step to determine This study proposes a method
the pretreatment residual pericervical root dentin. Objective: To determine and compare the to determine the dimensions of
residual root dentin and canal width using digital periapical radiography (DPR) and cone-beam structures at the apical limit of
computed tomography (CBCT) at the apical limit of the pericervical area (PCA) in mandibular the pericervical area using
first molars. Methods: DPR and CBCT images of 60 patients with age between 22 and digital periapical radiographs
76 years were used to determine (a) the mesiodistal widths of the root canal (pericervical and cone beam computed
dimensions [PCL]-C) and the root (PCL-R) of mandibular first molars at the apical limit of the tomography, providing
PCA and (b) the intracanal distance from the apical limit of the PCA to the radiographic apex baseline information that could
(intracanal distance [ICD]). The correlation between the PCL and ICD measurements obtained serve as a guide for
from DPR and CBCT were evaluated. Results: Values between 0.10–0.80 mm and customized decisions during
0.00–1.10 mm were obtained for PCL-C using DPR and CBCT respectively (95% CI). The endodontic therapy.
PCL values between 0.90–2.30 mm and 0.00–2.30 mm were obtained from DPR and CBCT
respectively (95% CI). The ICD ranged between 4.6–12.3 mm in DPR and 4.40–12.0 mm in
CBCT (95% CI). The comparative analysis showed differences from 20.9 to 0.5 mms for PCL
and 22.00 to 1.5 mms for ICD between DPR and CBCT techniques respectively.
Conclusion: The PCL and ICD determined from DPR and CBCT provided the pericervical
dentin metrics that could be utilized clinically as a guideline for decision-making in endodontic
treatment. (J Endod 2024;50:637–643.)

KEY WORDS
Cone-beam computed tomography; periapical radiography; apical limit of pericervical dentin;
root canal size; dental wall size; PCL; ICD
From the *Faculty of Dentistry,
Universidad Central de Venezuela,
The recent trends in minimally invasive endodontic treatment rely on utilizing conservative endodontic Caracas, Venezuela; †Faculty of Dentistry,
University of Toronto, Toronto, Ontario,
cavities and canal preparations1. The goal is to preserve maximum bulk of dentin so as to reduce the risk
Canada; and ‡Department of Dentistry,
of fracture in endodontically treated teeth2. The pericervical dentin, which is located 4 mm coronal and Mount Sinai Health System, Mount Sinai
4 mm apical to the alveolar crest level is emphasized to be crucial for distributing occlusal forces to the Hospital, Toronto, Ontario, Canada
root and surrounding bone, contributing to the biomechanical integrity of the root-filled teeth3. Due to the Address requests for reprints to Carlos
conical configuration of the root and the root separation that occurs in most posterior teeth, the apical Boveda Z., Centro de Especialidades
limit of the pericervical region presents the minimal dentin bulk of this area. Moreover, the subgingival Odontologicas, Piso 3, Avenida Principal
location renders this region, challenging for clinical assessment. Thus, root dentin at the apical limit of the de Chuao, Caracas 1060, Venezuela.
E-mail address: [email protected]
pericervical area (PCA), which is located 6 mm apical to the cemento-enamel junction, and approximately 0099-2399/$ - see front matter
4 mm apical to the alveolar crestal bone in healthy conditions is of particular significance4.
Copyright © 2024 American Association
Endodontic cavity preparation results in significant increase in root flexure, root deformation and of Endodontists.
decrease in fracture resistance, which may eventually contribute to the decrease in mechanical integrity of https://doi.org/10.1016/
endodontically treated teeth5. Endodontic cavities also increased tensile stress distribution at the cervical j.joen.2024.02.003

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aspect of the root6,7. In addition, any eccentric validation. Research on root canal as the initial width of the root canal wall, as
loss of root canal dentin during canal instrumentation does not relate the initial parameters to define for the final root canal
preparation reduces flexural resistance of the measurement of the root canal width, as well preparation.
root, altering the stress distribution pattern,
while generating a greater distribution of
stress, principally in the bucco-lingual direction
of root8. Factors that increase the degree of
root flexure may increase the propensity of
vertical root fracture9,10. Conservative access
and preparation techniques may be able to
significantly decrease cervical dentin
removal11.
Digital periapical radiography (DPR) is
widely used to assess dental anatomy in
clinical practice12. This technique offers
clinically relevant information at relatively low
cost and radiation dose. Regardless of their
widespread use, periapical radiographs
present certain limitations due to the two-
dimensional nature of this technique and
overlapping anatomical structures13. Thus,
most conventional periapical radiographic
images have suggested the root canals to be
round, while several reports have emphasized
the high prevalence of oval canals in human
teeth14,15. Cone-beam Computed
Tomography (CBCT), on the contrary, offers
high-quality three-dimensional images of the
maxillofacial hard tissues, facilitating more
accurate clinical assessments16. CBCT has
revealed a strong correlation with the
histology, which is considered the gold
standard17. Even though there is no current
consensus on the choice of technique for
preoperative endodontic evaluation of dental
morphology, diagnosis, and treatment
planning, it is widely accepted that CBCT can
be utilized when the information from
periapical radiographs is insufficient or
additional details are required18,19. CBCT has
been employed to measure root dentin
thickness and to predict dentin thickness after
endodontic procedures20.
The concept of working width in
endodontic treatment refers to the initial and
final dimensions, after the pulp space is
prepared, at any point of the root canal,
measured perpendicular to the root axis21. It
has been utilized clinically mainly to appreciate
the width of pulp space at the level of apical
foramen21. Because the pulp space is
irregular, the idea of a precogitated canal
preparation conflict with the anatomical reality
of root and canal morphology, where the
horizontal widths of the canal may vary at each
point of the root canal space. The relationship
between these values defines the classification FIGURE 1 – Apical limit of the pericervical area. (A) Schematic location, 6 mm apical to the enamel-cement junction
with which the root canal space can be (Illustration by Dr Francois Vigouroux). (B) Location on DPR using digital software measuring tools. (C) Location on CBCT.
geometrically categorized horizontally The tomographic axes are relocated based on the MFM, achieving a sagittal plane perpendicular to the mesio-distal axis,
(rounded, oval, etc.)21. Currently, determining a coronal plane perpendicular to the bucco-lingual axis and an axial plane perpendicular to the coronal-apical axis. The
the extent of root canal preparation is generally sagittal section is positioned median to the MFM buccal and lingual limits. The axial slice is selected 6 mm apical to the
based on subjectivity rather than scientific enamel-cement junction. CBCT, cone-beam computed tomography.

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 The endodontic literature and clinical would compare between CBCT and DPR. MATERIALS AND METHODS
guidelines lack techniques and protocols that The purpose of the current study was to
The Universidad Central de Venezuela School of
allow customized root canal preparation and develop a measurement protocol to determine
Dentistry BioEthics Review Board approved this
shaping strategy that are carried out at the (a) the mesio-distal width of the root canal
study, CB-134-2020. From a list of 42,334
most apical level of the pericervical dentin, an (pericervical dimensions [PCL]-C) and root
patients who attended the Radiology
area that is critical from a biomechanical (PCL-R) of mandibular first molars (MFM) at
Department of Centro de Especialidades
standpoint of an endodontically treated tooth. the apical limit of the PCA (Fig. 1A) as well as
Odontolo
gicas in Caracas, Venezuela, from
Even though CBCT has been validated for (b) the intracanal distance from the apical limit
January 1, 2012 to August 31, 2020, 5,612
measuring dental structures, its use for this of the PCA to the radiographic apex
endodontic patients were identified, where 287
particular purpose has not been reported. (intracanal distance [ICD]) using DPR (Fig. 1B)
met the following inclusion criteria: (a) Patients
Furthermore, it is unknown how these values and CBCT images (Fig. 1C).

FIGURE 2 – PCL and ICD measurements of the images in the mandibular first molar at the level of the apical limit of the pericervical area: (A) DPR. (B) CBCT. CBCT, cone-beam
computed tomography; DPR, digital periapical radiography.

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who have on file an orthograde DPR of the MFM One hundred eighty-three records were and inserted into the Carestream Dental
and a CBCT of the corresponding mandibular selected for the study. A sample calculation Imaging Software database. CBCT studies
molar area, both records obtained at the same based on the formula for comparing two repeated were obtained with the Kodak CS9000 3D
time. (b) Patients age between 18 and 76 years. means in a group, with a confidence level of 95% Extraoral Imaging System with a resolution of
(c) Posterior mandibular anatomical areas with and a significance of 5%, and using a 1-sided 0.076 mm voxel size. The tomographic axes of
teeth without previous root canal treatment. contrast, yielded a sample of 60 elements, each study were relocated based on the MFM,
The following exclusion criteria were also selected using simple random sampling without achieving a sagittal plane perpendicular to the
considered: (a) Presence of more than two replacement. From each selected patient the mesio-distal axis, a coronal plane
canals in the mesial root and more than 1 canal following information was obtained. perpendicular to the bucco-lingual axis and an
in the distal root of the MFM. (b) Presence of axial plane perpendicular to the coronal-apical
1. Age: in years
dental development anomalies of the MFM axis. The axial section was standardized 6 mm
2. Gender: Female or Male classification
(invaginations, enamel hypoplasia, apical to the enamel-cement junction and the
3. MFM, PCL, and ICD dimensions (mms)
amelogenesis imperfecta, enamel, or dentin sagittal section were selected midpoint
from the digital periapical radiographic
dysplasia, among others). (c) Presence of between MFM buccal and lingual limits. Three
image (Fig. 2A)
internal and/or external resorptions, as well as previously calibrated observers (two
4. MFM, PCL dimensions from the axial
loss of structure that alters the normal dental endodontists and one general practitioner)
tomographic slice at the apical limit of the
anatomy. (d) Presence of dental implants in the analyzed at different times the DPR of the MFM
PCA (Fig. 2B).
radiographic and/or tomographic image of the and the tomographic slices of the same tooth
5. MFM, ICD dimensions from the median
area. (e) MFM with dental procedures that (Fig. 3). The calibration process consisted of
sagittal tomographic slice (Fig. 2B).
significantly alter the normal dental anatomy. (f) four theoretical meetings where the concepts,
MFM with restorations or lesions that prevent The DPR images were obtained using criteria, technique and reference points to
the location of the cement/enamel junction from the long parallel cone technique in XCP-type carry out the measurement process were
being clearly identified in their images. (g) Teeth devices over reusable digital phosphor plates, deepened. Also, thirteen patients not included
with anatomical variations in shape and size number 2, with a resolution of 17 lp/mm in the final sample were selected and two
structure (microdontia, taurodontism, radix (Carestream Health, Rochester, NY), exposed series of measurements were carried out to
entomolaris and paramolaris, conoidism or with an ultra-high frequency X-ray unit, model evaluate the agreement. The comparison
concrescence, among others). Based on these CS2200 (70 kV for 0.205 s). The plates were between these calibration measurements
criteria 104 cases were excluded. processed in a Carestream CS7600 scanner resulted in the calculation of Lin’s correlation

FIGURE 3 – Typical images from DPR and CBCT used to measure: (A) PCL. (B) ICD. CBCT, cone-beam computed tomography; DPR, digital periapical radiography.

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TABLE 1 - Basic Statistics of the Measurements Obtained with Digital Periapical Radiographs

Mean Median Typical Smallest Highest Range:

DPR measurements (Ӯ) (Me) Dev. (S) CI 95% value (Sv) value (HV) (Mv–HV)
R1.- Size of the distal root canal 0.48 0.50 0.11 (0,47; 0,56) 0.30 0.80 0.50
R2.- Size of the mesial root canal 0.28 0.30 0.08 (0,26; 0,29) 0.10 0.50 0.40
R3.- Size of the distal wall of the distal root 1.70 1.70 0.26 (1,66; 1,73) 1.30 2.30 1.00
R4.- Size of the mesial wall of the distal root 1.35 1.30 0.22 (1,31; 1,38) 0.90 1.90 1.00
R5.- Size of the distal wall of the mesial root 1.27 1.20 0.20 (1,24; 1,30) 0.90 1.90 1.00
R6.- Size of the mesial wall of the mesial 1.50 1.50 0.21 (1,47; 1,53) 1.10 1.90 0.80
root
R7.- Distance from the center of the distal 8.87 9.10 1.32 (8,67; 9,06) 4.60 11.90 7.30
canal at the apical limit of the pericervical
area to the radiographic apical limit of the
distal root
R8.- Distance from the center of the mesial 9.16 9.30 1.30 (8,96; 9,35) 5.90 12.30 6.40
canal at the apical limit of the pericervical
area to the radiographic apical limit of the
mesial root

and agreement indices with minimum values of viewing distractors. Only the conventional light and 45% were female (27). 53.3% (32 teeth) of
0.37 and maximum values of 0.99, reflecting of the room was allowed, without any kind of the sample were left MFM and 46.7% (28
adequate calibration. The imaging studies noise or interruption of the process. teeth) were right MFM. Distributed 31.7% (19
analyzes were performed with the Carestream teeth) in patients between 22 and 40 years,
Dental Imaging Software application (CS 48.3% (29 teeth) in patients between 41 and
v7.0.19 and CS3DI v3.8.7.0) on 2400 Apple
RESULTS 58 years and 20% (12 teeth) in patients
iMacs model A1225. In DPR and CBCT The inter and intraobserver agreement between 59 and 76 years.
images, the position of PCL was established, calculations based on 76 individual Lin’s The statistical parameters were
and measurements were made, with the use of Concordance Correlation Coefficients determined for the eight measurements made
the digital measurement tool in the software. In calculated in two rounds reflect a very in digital periapical radiographs and the eleven
tomography, both axial and sagittal sections adequate calibration as they show almost measurements made in each CBCT of the sixty
were chosen for measurements. The perfect agreement in 71.1% of cases, patients, such as Mean, Median, Standard
radiographic and tomographic analyzes for substantial in 18.4% of the cases, moderate in Deviation, 95% Confidence Interval, Minimum
each patient was spread out by at least 7.9%, and poor in 2.6% of the cases. The Value, Maximum Value and the Range between
24 hours, while two rounds of observations study sample consisted of sixty individuals at these values. (Tables 1 and 2). For the analysis
were performed to control for observer fatigue. an age range between 22 and 76 years (mean of agreement between techniques, the normal
Special consideration was taken to have no age 48.3 years), of which 55% were male (33) Q-Q graph, issued by SPSS was used, being

TABLE 2 - Basic Statistics of the Measurements Obtained with Cone-beam Computed Tomography

Mean Median Typical Smallest Highest Range:

CBCT measurements (Ӯ) (Me) Dev. (S) CI 95% value (Sv) value (HV) (Mv–HV)
T1.- Size of the distal root canal 0.51 0.50 0.16 (0,48; 0,53) 0.20 1.10 0.90
T2.- Size of the mesiobuccal root canal 0.34 0.30 0.13 (0,32; 0,36) 0.00 0.80 0.80
T3.- Size of the mesiolingual root canal 0.31 0.30 0.10 (0,30; 0,33) 0.00 0.50 0.50
T4.- Size of the distal wall of the distal root 1.44 1.40 0.25 (1,40; 1,47) 0.90 2.30 1.40
T5.- Size of the mesial wall of the distal root 1.21 1.20 0.30 (1,17; 1,26) 0.60 2.30 1.70
T6.- Size of the distal wall of the 1.24 1.30 0.22 (1,21, 1,27) 0.70 1.80 1.10
mesiobuccal canal
T7.- Size of the mesial wall of the 1.28 1.30 0.18 (1,26; 1,31) 0.80 1.70 0.90
mesiobuccal canal
T8.- Size of the distal wall of the 1.24 1.20 0.22 (1,20; 1,27) 0.70 1.80 1.10
mesiolingual canal
T9.- Size of the mesial wall of the mesio- 1.28 1.30 0.17 (1,25; 1,31) 0.80 1.60 0.80
lingual canal
T10.- Distance from the center of the distal 8.72 9.00 1.35 (8,52; 8,92) 4.40 11.80 7.40
canal at the apical limit of the pericervical
area to the radiographic apical limit of the
distal root
T11.- Distance from the center of the mesial 8.96 9.10 1.32 (8,77; 9,16) 5.90 12.00 6.10
canal at the apical limit of the pericervical
area to the radiographic apical limit of the
mesial root

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TABLE 3 - Differences in mms from digital periapical Coefficients were compared between DPR one distal canal), while exhibiting high
radiography and cone-beam computed in PCL and ICD and CBCT measurements. The use of a clearly propensity for vertical root fracture25. It should
Measurements (% of Cases) established protocol and criteria increases the also be noted that the present study was
quality of studies that require the involvement limited to MFM without previous endodontic
Differences % % of several investigators22. In addition, the interventions. Further studies are essential for
(mms) PCL ICD findings in this study provides PCL and ICD other types of teeth.
measurements as the average, minimum Shaping procedures performed in root
22.00 — 0.3
(lowest), maximum (highest), and range values. canal treatment invariably led to a reduction in
21.10 — 0.3
21.00 — 0.3 It should be noted that all the minimum values pericervical dentin structure26. Ideally, during
20.90 0.1 0.3 are always less than the measured range, while the preparation of the root canal system,
20.80 — 1.6 the maximum values does not reach twice the instruments, and techniques should be
20.70 0.3 3.0 magnitude of the same range. As an example, adapted or selected based on the initial
20.60 2.5 3.3 the CBCT measurement of mesio-distal dimensions of the canal space to preserve
20.50 4.8 5.0 aspect of distal root canal showed a mean maximum dentin while maintaining the initial
20.40 8.1 6.4 value of 0.51 mm (minimum: 0.2 mm; dimensions of the structure and space. Lack of
20.30 6.1 12.8 maximum: 1.1 mm; range: 0.9 mm). This these values and canal/root forms make these
20.20 9.5 17.5
numerical distribution highlights the relevance objectives an uncertain exercise. Thus, it
20.10 17.1 20.0
of considering individual measurements rather becomes relevant to develop techniques and
0.00 22.1 12.3
0.10 19.1 6.9 an average or range in decisions where these protocols that allow characterization of the
0.20 7.4 3.3 measurements are important. baseline dental structures. The differentiation
0.30 2.1 2.8 The measurements obtained with CBCT between an acceptable and an excessive
0.40 0.6 2.2 are considered highly reliable; yet it is tooth structural alteration, should always be
0.50 0.2 1.4 important to compare its results with more determined from the baseline tooth structure
1.50 — 0.3 commonly used techniques. The PCL values prior to the treatment. The parameters
Total 100 100 obtained in the study from DPR varies from determined in this study can be employed to
20.9 to 0.5 mm when compared to those determine the individualized baseline metrics
able to verify in all cases the data of the variables obtained with CBCT and from 22.0 to 1.5 in for subsequent steps in endodontic treatment.
were distributed in a normal way. ICD measures (Table 3). This result can be
The differences between the explained considering the characteristics of
periapical radiographs, where variations in the
CONCLUSIONS
measurements from DPR and CBCT images
were also analyzed, both for PCL and ICD angulation of the radiograph and the projection This study proposes a noninvasive method to
measures, showing how many measurements produce changes in size, shortening or determine the dimensions of root canals/root
were equal, and how many differed in intervals lengthening the resultant dental image23. at the apical limit of the pericervical dentin of
of 0.1 mm (Table 3). PCL measurements comparison mandibular first molars as well as the intracanal
between DPR and CBCT results in 22.1% of distance from the apical limit of the pericervical
cases with no differences, 36,2% showed dentin to the radiographic apex using CBCT
DISCUSSION 0.1 mm difference, 16.9% 0.2 mm and 8.2% and periapical radiographs. These
Structural assessment of the pericervical 0.3 mms. 16.6% of the cases showed measurements provided baseline dimensions
dentin, particularly at the PCL has a unique 0.4 mms or more. For ICD measurements, of a biomechanically critical region of the tooth.
value since it is the region with minimum dentin 12.3% of cases showed no differences, 26,9% These easy to apply measurements
bulk locale in the MFM. The precise knowledge showed 0.1 mm difference, 20.8% 0.2 mm demonstrated high correlation between
of ICD allows to relate the metrics of the and 15.6% 0.3 mms. 24.4% of the cases observers. These metrics will serve as a guide
endodontic instruments to the dimensions of showed 0.4 mms or more. How much for customized decisions on the pericervical
dentin bulk at this region, aiding an accurate difference between these measurements is dentin prior to endodontic therapy.
anticipation of structural changes during acceptable for the purposes of considering
endodontic therapy. This customized them similar for making clinical decisions is a
preoperative information will offer the value that has to be determined in the future. ACKNOWLEDGMENTS
possibility of selecting corresponding The mandibular first molar (MFM) was The authors deny any conflicts of interest
endodontic instruments for each patient. The chosen in this investigation since it is the most related to this study.
tested protocol in this study was effective in frequently endodontically treated tooth24. Funding from the Canada Research
obtaining reliable results. When used by three Moreover, this tooth predominantly displays Chair Program (AK) and Dr Lloyd and Mrs Kay
observers, it showed very similar results when the configuration of two roots (1 mesial and 1 Chapman Chairship (AK) is also gratefully
Lin’s Correlation and Concordance distal) and three canals (two mesial canals and acknowledged.

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