Dentomaxillofacial Radiology (2009) 38, 169173 2009 The British Institute of Radiology http://dmfr.birjournals.

org

CASE REPORT

Detection of jaw and root fractures using cone beam computed tomography: a case report
. . D I lgu y*, M I lgu y, E Fisekcioglu and G Bayirli
Department of Oral Diagnosis and Radiology, Yeditepe University Faculty of Dentistry, Istanbul, Turkey

The aim of this case report is to demonstrate jaw and root fractures using a combination of cone beam CT (CBCT), CT and conventional radiographs. In this presentation a 23-year-old female patient who was referred to our dental clinic with a severe facial trauma is reported. The patient was initially examined by a general dentist and a fracture in the mandibular right canine region was diagnosed on the CT images. Once referred to our clinic, the raw CT images were re-evaluated by three maxillofacial radiologists in the Oral Diagnosis and Radiology Department. Two new fracture lines that were not reported on the original CT analysis were diagnosed among the raw CT images. More detailed information was obtained about dentoalveolar fractures with CBCT compared with CT and conventional radiography. Dentomaxillofacial Radiology (2009) 38, 169173. doi: 10.1259/dmfr/54020205 Keywords: fractures; cone beam computed tomography; computed tomography

Introduction Fractures of the maxillofacial region present difficulties for the dentist, especially when the fractures are localized to dental and paradental structures. Most maxillofacial traumatic injuries involve the dentition alone (50%), or both the dentition and adjacent soft tissue (36%).1 The first clinical and radiographic examination of the traumatized patient is crucial to determine the initial diagnosis, severity of the injury, treatment plan and to create a baseline for follow-up. Common diagnostic aids for pulpal and periapical conditions are percussion, palpation, tooth mobility, coronal colour changes, pulp sensitivity tests and radiographs.2 The NewTom 3G model QR-DVT 9000 CT X-ray system is a dedicated X-ray imaging device that acquires a 360 rotational X-ray sequence for use in diagnostic support in dental radiology (with a particular reference to patient evaluation and the monitoring of implantations) and in the field of maxillofacial surgery.3 The aim of this case report is to demonstrate jaw and root fractures with a combination of radiography techniques.
lgu *Correspondence to: Prof. Dr Assoc. Dilhan I y, Yeditepe Universitesi Dis Hekimligi Fakultesi, Bagdat cad. No 238, 34728 Goztepe-Istanbul, Turkey; E-mail: ilguy@yeditepe.edu.tr Received 14 February 2008; revised 2 April 2008; accepted 3 April 2008

Case report A 23-year-old female patient was referred to our dental clinic with a severe traumatic injury to her face due to a car accident 1 week before. The patient was initially examined by her dentist, who diagnosed a fracture in the right mandibular canine region with CT (Figure 1). Upon clinical examination, the right mandibular canine did not respond to an electric pulp sensitivity test (Vitality Scanner; Analytic Technologies, Redmond,

Figure 1 Fracture in the right mandibular canine region on CT scan (arrow)

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Figure 2 The fracture in the right mandibular canine region on the panoramic radiograph

Figure 3 Oblique root fracture (arrows) of maxillary left first premolar (tooth no. 24) on cone beam CT
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Figure 4 Oblique root fractures of the maxillary right first premolar and the mandibular right second premolar (teeth 14 and 45) on cone beam CT (CBCT) (arrows). The vertical fracture line on the alveolar bone between the right maxillary premolars (teeth 14 and 15) on CBCT (bottom right arrow)

WA) or to a cold sensitivity test at 50 C (Endo Frost; Roeko, Langenau, Germany). The tooth was not mobile, but was sensitive to percussion. The adjacent teeth were asymptomatic and responded normally to cold and electric pulp tests. Intraoral examination revealed that the maxillary premolars were sensitive to percussion. Periapical radiographs did not show any fracture (Trophy Novalix, Croissy-Beaubourg, France). A fracture in the right mandibular canine region could clearly be detected on the panoramic radiograph (Planmeca Promax, Helsinki, Finland) (Figure 2). For a further examination, digital images were taken with the NewTom 3G DVT 9000 (Quantitative Radiology s.r.l., Verona, Italy). The NewTom analysis at 0.5 mm sagittal cuts was performed. Cross-sectional views showed oblique root fractures in the maxillary right first premolar, maxillary left first premolar and mandibular right second premolar (teeth numbers 14, 24, 45) (Figure 34) and a vertical fracture line on the alveolar bone between the maxillary right first and second premolars (teeth 14 and 15; Figure 4). Also, a fracture line in the mandibular left canine region was observed on coronal CBCT view (Figure 5). A rigid splint with wire and composite resins extending from

the maxillary left canine to the right maxillary canine was applied.

Discussion The main disadvantages of CT are the high radiation dose compared with plain-film radiography and the high cost of the equipment. Mah et al6 compared the tissue-absorbed dose of CBCT and other CT imaging modalities. They concluded that the effective dose for the imaging of the maxillomandibular volume with a NewTom 9000 is significantly lower than that with CT imaging methods. In the present case, only a thin fracture line was observed on the right mandibular canine region according to the CT scan (Figure 1). On the other hand, bilateral alveolar fracture lines were seen clearly on coronal CBCT view (Figure 5). The bilateral alveolar fracture lines were not listed in the original report of the CT scan. The axial slice thickness is 0.7 mm for CT analysis and 0.2 mm for the CBCT, and the coronal slice thickness is 0.7 mm and 0.5 mm, respectively. The thickness of coronal slices is quite
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Figure 5 Bilateral fracture lines on coronal cone beam CT view (arrows)

similar, which raises the question of why the fracture line in the mandibular left canine region was detected only in CBCT analysis and not reported in CT. This situation may be due to the experience of both the medical radiologist, who may not have been familiar with maxillofacial images, and the maxillofacial radiologist who examined the CBCT images. In the present case, the raw CT images were re-evaluated by three maxillofacial radiologists in the Oral Diagnosis and Radiology Department. In addition, two new fracture lines of the mandible that were not reported with CT analysis by the medical radiologist, despite the slice thickness being 0.7 mm, were diagnosed on the raw CT images (Figure 6). This may be due to the medical radiologist not being specialized in the maxillofacial region. More

detailed information may be provided by a maxillofacial radiologist regarding images of the maxilla and mandible. The NewTom 3G has the lowest radiation levels in the industry. The 3G has a unique pulsed X-ray system that only turns on the X-ray source when an image is being taken and automatically adjusts the radiation dosage based on patient size.7 Ludlow et al8 reported that imaging a maxillomandibular volume with the NewTom 3G results in an effective dose of 57 mSv and, according to Ngan et al,9 traditional medical CT results in an effective dose of 1400 mSv for a maxillary CT scan and 2100 mSv for a maxillomandibular examination. Mora et al10 demonstrated that local CT significantly improves the detection of longitudinal fractures in vitro compared with conventional periapical radiography. In the present case, the patient received panoramic, periapical CT and CBCT, which is incompatible with the ALARA (As Low As Reasonably Achievable) principle. Essentially, the CT scan was not necessary for the patient even though it had been taken by another dentist who examined the patient first. The dentist should be aware of the new radiographic techniques. The conventional radiograph is a two-dimensional shadow of a three-dimensional (3D) object. Detection of root fractures on radiographs is most influenced by the direction of the radiation beam, which must pass through the fracture line.11 3D imaging overcomes this major limitation by allowing us to visualize the third dimension while at the same time eliminating superimpositions.12 The periapical radiographs which were taken of the patient showed no root fracture. In conclusion, CBCT, CT, panoramic and periapical radiographs were combined in the present case to provide more detailed information. Futhermore, the clinicians should be competent in using the appropriate radiography techniques in varied cases.

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Figure 6 The lingual fracture lines diagnosed by a maxillofacial radiologist on the raw CT scans (arrows)
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