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Contents lists available at ScienceDirect

Annals of Anatomy
journal homepage: www.elsevier.com/locate/aanat

Effects of voxel size and resolution on the accuracy of endodontic

length measurement using cone beam computed tomography
Ali Murat Aktan a,∗ , Cihan Yildirim b , Emrah Karataşlıoğlu b , Mehmet Ertuğrul Çiftçi c ,
Fatih Aksoy b
a
Department of Dentomaxillofacial Radiology, Faculty of Dentistry, University of Uşak, Uşak, Turkey
b
Department of Endodontics, Faculty of Dentistry, University of Gaziantep, Gaziantep, Turkey
c
Department of Dentomaxillofacial Radiology, Faculty of Dentistry, University of Gaziantep, Gaziantep, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: An accurate determination of the working length is indispensable for successful endodontic treatment.
Received 24 February 2016 The aim of this study was to determine the influence of the voxel size and resolution of CBCT on measuring
Received in revised form 11 April 2016 root canal working length. Thirty extracted single-rooted permanent teeth were used for this study. The
Accepted 6 May 2016
working lengths of the teeth were determined by a researcher inserted a K-file into each canal until
Available online xxx
the tip became visible through the major foramen. The file was withdrawn until its tip was seen at
the level of the coronal-most border of the major foramen under. The rubber stop was adjusted to the
Keywords:
occlusal reference and the distance from the stop to the false tip was measured with digital calipers and
CBCT
Resolution
recorded as the actual working length. The CBCT images were obtained with a Planmeca ProMax 3D Mid
Voxel (Planmeca, Helsinki, Finland) using four sets of settings: from voxel size 0.5 mm to voxel size 1.0 mm.
Working length These measurements were compared with actual lengths (as a control group) using Analysis of Variance
and the Dunnett Post Hoc Test. The Pearson correlation coefficient (r) and 95% confidence intervals were
calculated to compare all measurement methods. The significance level was set at P < 0.05. No significant
difference was found among CBCT groups and working length. A highest correlation was found between
the actual length and smallest voxel size and highest CBCT measurements (r = 0.94). CBCT imaging can be
used endodontic working length measurement and the smallest voxel size and highest resolution yielded
more accurate results.
© 2016 Elsevier GmbH. All rights reserved.

1. Introduction of the WL can be inaccurate, depending on the direction and extent

An accurate determination of the working length (WL) is indis-
pensable for successful endodontic treatment (Sjogren et al., 1990;
Ng et al., 2008; Jeger et al., 2012; Connert et al., 2014). However,
the location of the apical position constitutes a persistent chal-
lenge in clinical endodontics. The use of an electronic apex locator
(EAL) (ElAyouti et al., 2002; Ng et al., 2008), periapical radiograph
(Williams et al., 2006; Vieyra and Acosta, 2011) or both (Ravanshad
et al., 2010; Liang et al., 2013) is well documented for measuring
the root canal WL.
In endodontics, radiographs are essential for diagnosis and for
evaluating treatment success or failure. Radiographic assessments
∗ Corresponding author at: Uşak Üniversitesi, Dişhekimliği Fakültesi, Ağız, Diş
ve Çene Radyolojisi A.D., Kampus, Uşak, Turkey. Tel.: +90 5327074499; fax: +90276
221 22 32.
E-mail address: alimurataktan@yahoo.com (A.M. Aktan).
of the root curvature and the position of the apical foramen relative
to the anatomical apex (Larheim and Eggen, 1979; Bhakdinaronk
and Manson-Hing, 1981; Kazzi et al., 2007). In addition, the super-
imposition of bony structures hinders the identification of the
radiographic apex of some teeth. Moreover, the interpretation of
radiographs is subjective and involves quality issues like distor-
tion and magnification (Vajrabhaya and Tepmongkol, 1997; Weiger
et al., 1999).
One of the most remarkable innovations in root canal imag-
ing which eliminates the above mentioned disadvantages related
to the periapical radiographs is the three-dimensional (3D) eval-
uation of the root canal morphology using cone beam computed
tomography (CBCT) (Mozzo et al., 1998; Estrela et al., 2008; Patel,
2009; Michetti et al., 2010). Reliability of two-dimensional radio-
graphic techniques is suspected because of image magnification
and low reproducibility, since they ensure two-dimensional views
of complicated three-dimensional objects (Baumrind and Frantz,
1971). In recent years, CBCT has become a well-accepted method

http://dx.doi.org/10.1016/j.aanat.2016.05.005
0940-9602/© 2016 Elsevier GmbH. All rights reserved.

Please cite this article in press as: Aktan, A.M., et al., Effects of voxel size and resolution on the accuracy of endodontic length measurement
using cone beam computed tomography. Ann. Anatomy (2016), http://dx.doi.org/10.1016/j.aanat.2016.05.005
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Fig. 1. Working length measurements using coronal (a), sagittal (b), axial (c), and 3D images (d) of CBCT with Tooth HD 50 mm × 80 mm FOV and 0.1 mm voxel size settings.

for the measurements of anatomic structure of craniofacial region
due to its lower radiation doses and quicker image scanning times
in comparison with computed tomography (Guijarro-Martinez and
Swennen, 2011). While a few studies have evaluated the accuracy
or validity of CBCT for measuring the endodontic, no consensus
exists WL (Janner et al., 2011; Jeger et al., 2012; Liang et al., 2013;
Connert et al., 2014; Lucena et al., 2014): some authors concluded
that CBCT can be used to determine the endodontic WL in combi-
nation with EAL (Janner et al., 2011), while others stated that the
limited CBCT scans can be used for WL measurements (Jeger et al.,
2012; Liang et al., 2013). On the other hands, it revealed that elec-
tronic measurements were more reliable than CBCT scans for WL
determination (Lucena et al., 2014). These different results might
arise from the different voxel sizes used, since each study used dif-
ferent CBCT parameters, which affects image quality. Therefore, the
aim of this study was to determine the influence of the voxel size
and resolution of CBCT on measuring root canal WL.
2. Materials and methods
Thirty human mandibular anterior teeth were included in the
present study. Silicon putty was used to hold the teeth in the
arch model. Teeth with immature apices, metallic restorations,
fractures, root resorption, calcifications, or with previous endodon-
tic treatment as evidenced by a radiographic examination were
excluded from the study. Before the measurements, calculus and
soft tissue debris were removed from the teeth surfaces.
2.1. CBCT measurements
The CBCT images were obtained with a Planmeca ProMax 3D
Mid (Planmeca, Helsinki, Finland) using four settings: (1) voxel
size 0.1 mm, field of view (FOV) 50 mm × 80 mm, and high reso-
lution with 90 kV, 10 mA and 15 sn (Tooth HD group) (Fig. 1); (2)
voxel size 0.4 mm, FOV 50 mm × 80 mm, and low resolution with
90 kV, 6 mA, and 2.4 sn (Tooth LD group) (Fig. 2); (3) voxel 0.15 mm,
FOV 80 mm × 100 mm, and high resolution with 90 kV, 10 mA and
15 sn (Teeth HD group) (Fig. 3); and (4) voxel size 0.2 mm, FOV
100 mm × 150 mm, and high resolution with 90 kV, 10 mA, and
18 sn (Jaw HD group) (Fig. 4). To standardize imaging, the work-
ing model was placed on a tripod in a reproducible position. The
CBCT images were obtained by a dentomaxillofacial radiologist not
involved in any step of the endodontic measurements.
All CBCT measurements were performed by the same radiolo-
gist trained in CBCT diagnostic applications. Firstly, the root canal
of each tooth was placed in a vertical position so as to visualize,
whenever possible, the entire length of the canal in a single slice.
This procedure was repeated to obtain buccolingual and mesiodis-
tal sections of each tooth. A measurement line was traced from the
reference occlusal plane following the visible canal curvature in
the respective CBCT slice (Jeger et al., 2012). The arithmetic mean
of the buccolingual and mesiodistal measurements was recorded
as the CBCT WL. Apart from reformatting procedures and satu-
ration/contrast adjustment, the images were not modified. All of
the procedures were performed using Planmeca Romexis Viewer
(Planmeca Romexis; Helsinki, Finland).

Please cite this article in press as: Aktan, A.M., et al., Effects of voxel size and resolution on the accuracy of endodontic length measurement
using cone beam computed tomography. Ann. Anatomy (2016), http://dx.doi.org/10.1016/j.aanat.2016.05.005
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Fig. 2. Working length measurements using coronal (a), sagittal (b), axial (c), and 3D images (d) of CBCT with Tooth LD 50 mm × 80 mm FOV and 0.4 mm voxel size settings.

To measure the actual WL, the specimens were removed from
their molds and cleaned with water to remove deposits. K-file of the
same size used for the electronic measurement was inserted into
each canal until the tip became visible through the major foramen.
Then, the file was withdrawn until its tip was seen at the level of
the coronal-most border of the major foramen under a magnifying
glass (2.5×). The rubber stop was adjusted to the occlusal refer-
ence and the distance from the stop to the false tip was measured
with digital calipers and recorded as the actual length of the tooth
canal.
Descriptive statistics were used. The distribution of measure-
ments was assessed using one-way analysis of variance (ANOVA).
The Pearson correlation coefficients test was used for determina-
tion of the correlations between two groups. The measurements
were also evaluated using interclass correlation coefficients (ICC).
Confidence intervals of 95% were calculated to compare all mea-
surement methods. The significance level was set at P < 0.05. SPSS
for Windows version 22.0 packet program was used for statistical
analysis.
3. Results
The one-way ANOVA showed no significant differences between
the actual length and measurements of the four CBCT groups P:
0.95 (Table 1). The mean of the absolute difference between the
actual length and CBCT measurements was 0.02 mm for Tooth
HD group, 0.18 mm for Teeth HD group, 0.19 mm for Tooth LD
group, and 0.26 mm for Jaw HD group (Table 2). The Pearson cor-
relation coefficients comparing the actual and four CBCT groups
ranged from 0.834 to 0.940 (Table 3 and Fig. 5). The interclass
correlation coefficient ranged from 0.81 to 0.92 for the root canal
measurements.
Of the 30 canals, the CBCT measurements in the Tooth HD group
were accurate (±0.5 mm) in 20 canals (70%), short in 5, and long in

Table 1
Descriptive statistics regarding differences between CBCT and actual length measurements.

N Mean Std. deviation Std. error 95% confidence interval for mean Minimum Maximum P

Lower bound Upper bound

Working length 30 21.5 1.58 0.29 20.90 22.09 17.45 23.88

Tooth HD group 30 21.48 1.53 0.28 20.90 22.05 17.56 23.63
Tooth LD group 30 21.31 1.39 0.25 20.80 21.83 17.6 23.57 0.95
Jaw HD group 30 21.23 1.43 0.26 20.70 21.77 17.59 23.51
Teeth HD group 30 21.32 1.55 0.28 20.74 21.90 17.36 23.81

Total 150 21.37 1.48 0.12 21.72 21.61 17.36 23.88

Please cite this article in press as: Aktan, A.M., et al., Effects of voxel size and resolution on the accuracy of endodontic length measurement
using cone beam computed tomography. Ann. Anatomy (2016), http://dx.doi.org/10.1016/j.aanat.2016.05.005
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Fig. 3. Working length measurements using coronal (a), sagittal (b), axial (c), and 3D images (d) of CBCT with Teeth HD 80 mm × 100 mm FOV and 0.15 mm voxel size settings.

Table 2
Mean differences between CBCT groups and actual length measurement.

Group Group Mean difference Std. error Sig. 95% confidence interval

Lower bound Upper bound

Tooth HD group Working length −0.02 0.37 1 −0.98 0.93

Tooth LD group Working length −0.19 0.37 0.97 −1.14 0.77
Jaw HD group Working length −0.26 0.37 0.90 −1.22 0.70
Teeth HD group Working length −0.18 0.37 0.97 −1.13 0.78

5 canals. According to that result, Table 4 shows the distribution
of all CBCT measurements according to their accuracy. There were
no significant differences among the four CBCT groups P: 0.41. The
CBCT measurements in the Tooth LD group were less.
4. Discussion
With the advances in CBCT technology, pre-endodontic 3D
evaluations can be used to detect apical periodontitis, diagnose
resorptive lesions, and plan the endodontic treatment of complex
root canal anatomy (Cohenca et al., 2007; Patel et al., 2007; Patel,
2009, 2010). The few studies that have measured the WL using
CBCT have reported different results (Janner et al., 2011; Jeger
et al., 2012; Liang et al., 2013; Connert et al., 2014; Lucena et al.,
2014). A pilot study comparing CBCT with standard measurements
techniques concluded that CBCT could be useful for determining
the endodontic WL in combination with clinical measurements
(Janner et al., 2011). Another study that compared EAL and CBCT

Table 3
CBCT groups and actual length measurement showed correlation between the two measurements.

Working length Tooth HD group Tooth LD group Jaw HD group Teeth HD group
** ** **
Working length 1 .940( ) .834( ) .909( ) .924(** )
Tooth HD group .940(** ) 1 .928(** ) .958(** ) .976(** )
Tooth LD group .834(** ) .928(** ) 1 .936(** ) .946(** )
Jaw HD group .909(** ) .958(** ) .936(** ) 1 .955(** )
Teeth HD group .924(** ) .976(** ) .946(** ) .955(** ) 1
**
p < 0.05.

Please cite this article in press as: Aktan, A.M., et al., Effects of voxel size and resolution on the accuracy of endodontic length measurement
using cone beam computed tomography. Ann. Anatomy (2016), http://dx.doi.org/10.1016/j.aanat.2016.05.005
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Fig. 4. Working length measurements using coronal (a), sagittal (b), axial (c), and 3D images (d) of CBCT with Jaw HD 100 mm × 150 mm FOV and 0.2 mm voxel size settings.

WL measurements showed that the EAL measurements were more
reliable (Lucena et al., 2014). A prospective controlled clinical
study emphasized that CBCT can be used to measure endodontic
WL, but that further studies are needed to evaluate whether CBCT
can replace initial and WL periapical radiographs (Jeger et al.,
2012). Authors showed that CBCT based-root canal length mea-
surements are reliable and can be used to determine an accurate
endodontic WL (Liang et al., 2013; Connert et al., 2014). Based on
the literature, it can clearly be stated that different results on the
WL measurements result from different voxel sizes of the CBCT
scans. For that reason, the aim of the present study has been to
evaluate the influence of the different voxel sizes and resolutions
of the CBCT scans on the accuracy of endodontic WL measurements
compared with the AL measurements as a gold standard. According
to the present study, a strong correlation among AL and CBCT
measurements was found. Although all of the CBCT scans showed
reliable results, the smallest voxel size and highest resolution CBCT
scan measurements showed strongest correlation with the AL. In
Table 4
Distribution of the teeth according to their accurate, short, or long actual length
measurements and different CBCT parameters.
Accurate (%) Short (%)
Tooth HD group 21 (70) 5 (17)
Teeth HD group 20 (67) 7 (23)
Jaw HD group 15 (50) 11 (37)
Tooth LD group 16 (53) 9 (30)
addition, voxel size increases, the correlation between AL and CBCT
measurements was found to decrease. Therefore, when ALARA
principle and limited FOV typically producing a higher spatial res-
olution were considered (Patel et al., 2014), CBCT scanners which
provided the option to change the FOV size according to the clinical
situation may be more favorable than fixed FOV CBCT scanners.
In this in vitro study the mean absolute difference between AL
and CBCT scan measurements was found to be 0.02 for 0.2 mm
voxel size and HD resolution, 0.18 for 0.4 mm voxel size and
HD resolution, 0.19 for 0.2 mm and LD resolution, and 0.26 for
0.8 mm and HD resolution. It may indicate that CBCT can be
used for WL determination, since distances <0.5 mm are clinically
inapplicable, although these results suggested no statistically
significant differences between AL and CBCT scan measurements.
While authors found that 0.5 mm voxel size caused significant
differences between the AL and CBCT measurements (Lucena et al.,
2014), other investigators evaluated accuracy and reliability of
linear tooth and root measurements of the different CBCT voxel
sizes (0.2, 0.3, and 0.4 mm voxel sizes) and they found similar
results to the present study, being that no significant differences
were found between AL and CBCT measurements (Sherrard et al.,
2010); however, the 0.4 mm CBCT scans has a slightly lower
reliability than the other voxel sizes in accordance with the results
Long (%) of the present study. These small differences may result from the
4 (13) difficulty in clearly identifying the landmarks, since larger voxel
3 (10) sizes are associated with decreased spatial resolution. In addition
4 (10) to these, incongruity at correlation between CBCT and other WL
5 (17)
measurement methods has several factors including study design,

Please cite this article in press as: Aktan, A.M., et al., Effects of voxel size and resolution on the accuracy of endodontic length measurement
using cone beam computed tomography. Ann. Anatomy (2016), http://dx.doi.org/10.1016/j.aanat.2016.05.005
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Fig. 5. Correlations between four CBCT groups and actual length measurement.

tooth or canal morphology, specification of the imaging program,
and operator experience on the CBCT. In a study using different
tooth types, CBCT-based measurements were found to be more
accurate than apex locator-based measurement (Liang et al., 2013;
Connert et al., 2014) than the ones using single rooted teeth (Janner
et al., 2011; Lucena et al., 2014). A study which calculated WL
from horizontally sectioned teeth showed that CBCT scans were
not more reliable than electronic apex locator for determination
of endodontic WL (Lucena et al., 2014). CBCT measurement in this
study was performed by drawing a line between foramen and
reference point of the tooth. In the case of curved canals, tracing the
canal using multiplanar lines to follow the path of the canal may
be helpful to get more definite measurements in further studies. In
addition, different CBCT devices using different imaging programs
reveal many kinds of parameters. In addition, the same device
can produce differing images at different settings. Future studies
should take these parameters into account to display sensitivity.
5. Conclusion
Although all of the CBCT voxel sizes and resolutions used in
this study enabled reliable endodontic root canal measurement,
the smallest voxel size and highest resolution yielded more accu-
rate results. CBCT devices should be developed with consideration
to the ALARA principle, while allowing accurate, reliable, clinical
endodontic root canal measurements.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.aanat.2016.05.
005.
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