AUTOMATED WORKING LENGTH DETERMINATION OF MAXILLARY

ANTERIOR TEETH USING DEEP LEARNING AND COMPARISON WITH

STEREOMICROSCOPIC EVALUATION – AN EXPERIMENTAL STUDY

DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS

PRINCIPAL INVESTIGATOR:
DR MANJU MURUGAN (JUNIOR RESIDENT)
GUIDE:
DR PRASANTH BALAN (ASSOCIATE PROFESSOR)
CO-GUIDE:
DR VARNA R (ASSISTANT PROFESSOR)
DR JAYASREE S (PROFESSOR & HEAD OF DEPARTMENT)
DR POURNAMI P N (ASSOCIATE PROFESSOR, DEPT OF CSE, NIT)
 INTRODUCTION
• Accurate working length determination is paramount in Endodontics to reduce the risk of
procedural errors.
• Electronic apex locators may give inaccurate working length readings in varied canal conditions
during which radiographs play an essential role.
• Recent advances in Digital radiography make it a viable option for working length
determination.
• Automating this process provides quicker and more efficient working length determination
with reduced human intervention.
• Convolutional Neural Network is a popular type of Deep learning algorithm which upon
adequate training can aid in image recognition, object detection and image segmentation.
• In this study, the imagery data is provided in the form of digital periapical radiographs and
the outcomes correspond to the working length of the teeth as well as the extent to which
the file tip falls short of or beyond the radiographic apex.

OUTCOME
(Working length of the teeth)

Digital x-rays collected from RVG Data processing by the CNN-

Database for training the CNN- based learning model
based learning model
 RATIONALE OF THE STUDY
• Working length determination from digital periapical radiographs require manual calibration and
measurement which shows inter-examiner differences.
• The integration of Convolutional Neural Networks with digital radiography enables the analysis of
vast amounts of dental data with remarkable speed and accuracy.

REVIEW OF LITERATURE
• Ahmed ZH et al in Nov 2023 applied AI in diagnosing periapical lesions, root fractures, working length
determination, studying root canal anatomy and decision-making in endodontics for retreatment and found out
that the accuracy of AI in performing these tasks can reach up to 90%.
• Saghiri MA et al in Aug 2012 evaluated the accuracy of working length determination and found out that ANN
was more accurate than endodontists' determinations when compared with real working length measurements
by using the stereomicroscope.
• Saghiri MA et al in Oct 2011 developed a new approach for locating the minor apical foramen (AF) using an
artificial neural network (ANN) as a decision-making system showed that it had an accuracy of 93%.
 RESEARCH QUESTION
What is the efficacy of a deep learning model in accurately determining the working length
of straight, single-rooted teeth from periapical radiographs, and how does it efficiently
contribute in endodontic procedures?

AIM
The aim of the study is to develop and validate an AI-based learning model to determine the
working length of straight, single-rooted teeth from digital periapical radiographs and
compare the results with that obtained from stereomicroscopic studies.
 OBJECTIVES
1. To develop and train an AI-integrated learning model with data in the form of pre-operative
digital periapical radiographs of teeth to determine the coronal reference point and
radiographic apex.
2. To develop and train the learning model with data in the form of digital periapical radiographs
of teeth with an endodontic file placed 0.5 mm short of the radiographic apex and a
corresponding outcome for the image (Working length of the teeth).
3. To develop and train the AI-integrated learning model with data in the form of digital periapical
radiographs of teeth with an endodontic file placed within and a corresponding outcome for
the image (Short of or beyond the apex).
4. To evaluate the learning model by feeding radiographs of extracted straight single-rooted teeth
and obtain the outcome (Working length of the sample teeth).
5. To determine the extent to which the file is short of, beyond or at the minor apical diameter
from the digital periapical radiographs using the learning model.
6. To locate the minor apical diameter of the sample teeth using stereomicroscopic studies and
thereby establish the accurate working length of the teeth.
7. To assess the learning model by comparing the values obtained from the model to that obtained
from conducting stereomicroscopic studies.

HYPOTHESIS
• Null hypothesis: There is significant difference between the working length values obtained
from the learning model when compared to that obtained from stereomicroscopic studies.
• Alternate hypothesis: There is no significant difference between the working length values
obtained from the learning model when compared to that obtained from stereomicroscopic
studies.
 MATERIALS AND METHODS
STUDY DESIGN: In vitro study

STUDY SETTING: The study will be conducted in

• The Department of Conservative Dentistry and Endodontics, Government Dental college, Calicut
• The Department of Computer Science, National Institute of Technology, Calicut
• Department of Environmental engineering- National Institute of Technology, Calicut – Stereomicroscopic
examination.
STUDY PERIOD: Over a period of 18 months after ethical clearance.
SAMPLE SIZE SELECTION
The sample size required to train the model was found to be a minimum of 100 for obtaining accurate
outcomes according to the 10 times rule in deep learning.
The sample size required for validation and comparison of the model with stereomicroscopic examination
was estimated using Interclass Correlation Coefficient and was found to be 55.

N = 1 + 4 x (Zα + Zβ)2 C = 1 + 2θ0 θ0 = ICC0 θ1 = ICC1 Where, ICC0 = 0.8, ICC1 = 0.9,
(ln (C))2 1 + 2θ0 1 – ICC 0 1 – ICC1 Zα = 1.96, Zβ = 0.84
 INCLUSION CRITERIA
I] Development of the learning model
• Pre-operative periapical radiographs
of straight and single-rooted teeth and
those of the same teeth with the initial
apical file, captured from patients
indicated for root canal treatment
within the timeframe spanning the
study
II] Validation of the learning model
• Straight, single-rooted teeth
extracted for orthodontic or
periodontal purposes.
• Teeth with apical curvatures less than
30 degrees.
EXCLUSION CRITERIA
I] Development of the learning model
• Radiographic images characterized by
poor quality and artefacts
• Radiographs of multi-rooted, grossly
decayed, fractured teeth and teeth with
increased apical curvatures.
II] Validation of the learning model
• Multi-rooted teeth
• Teeth with increased apical curvatures
• Grossly decayed teeth
• Calcified teeth
• Fractured teeth
• Teeth with developmental anomalies
MATERIALS
• K-files (MANI, INC-Prime dental products Pvt Ltd)
• Disposable plastic syringes (BD Emerald syringe, Becton Dickinson)
• Distilled water
• Diamond Disk
• Round bur (Size 4, MANI Prime dental products Pvt Ltd)
• Sticky wax
• RVG Sensor (Confident Eco)
• X-ray unit
• Straight, single-rooted extracted teeth
• Desiccated skull for mounting the teeth
• RVG Sensor holder (Bluedent Innovations)

ARMAMENTARIUM
• Airrotor handpiece (NSK Ltd.)
• Micromotor handpiece (NSK Ltd., 35W)
• Stereomicroscope
 METHODOLOGY
For Developing and training the AI-integrated learning model

Digital periapical radiographs

Pre-operative radiographs Radiographs showing the initial file within the canal
(100 samples) (100 samples)

File at the apex File short of apex File beyond apex

Developed CNN-based learning

model
For validation of the AI-integrated learning model

Extracted teeth with K files within the canal

(100 samples)
(Fixed in the alveolar sockets of
desiccated skull & exposed)

CNN-based learning model

(Processing of input data)

Outcomes

File at the apex File short of apex File beyond apex

 In vitro comparison of results

Extracted teeth
(100 samples)

Teeth with file Teeth with file Teeth with file

at the apex short of apex beyond apex

Longitudinal sectioning of teeth

Stereomicroscopic examination to detect the minor apical

diameter & actual working length is obtained

Comparison of values obtained from the learning model

and stereomicroscopic examination

Results and Conclusion

PLAN OF ANALYSIS
Sensitivity, specificity and Receiver operating characteristics (ROC) with area under the curve (AUC) will be used to
validate the artificial intelligence model.
The reliability of the learning model was estimated using Interclass correlation coefficient.
Level of agreement between the two methods will be estimated using Bland Altmann analysis.

ETHICAL CLEARANCE
Study will be subjected to ethical clearance from Institutional Ethics Committee, Government Dental College, Calicut.
The waiver of informed consent was granted by the Institutional Research and Ethics Committee due to the
anonymized nature of the radiographs, ensuring patient confidentiality.
In accordance with the ethical guidelines established by the Indian Council of Medical Research (ICMR), this study
necessitates adherence to both non-disclosure agreement (NDA) and a Material Transfer agreement (MTA), both of
which will be duly submitted.

BUDGET
The cost of the study will be met by the investigator and the guide.
Estimated total expense – Rs 50,000/-
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