Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients

Gizem Karagöz Doğan; Yelda Polat Yavuz; Emin Caner Tümen

doi:10.7126/cumudj.1880006

EN TR

Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients

Abstract

Objective: This study aimed to quantitatively evaluate trabecular bone structural changes following root canal treatment (RCT) in pediatric patients using fractal analysis (FA) and to investigate its relationship with Periapical Index (PAI)–based healing. Methods: Forty-one single-rooted anterior teeth from patients aged ≤16 years were included. Periapical radiographs obtained immediately after treatment (T0) and during follow-up (T1) were analyzed. Fractal dimension (FD) values were calculated from standardized regions of interest. Periapical healing was assessed using PAI and classified as healed (PAI < 3) or non-healed (PAI ≥ 3). Comparisons were performed according to follow-up duration (≤1 year and >1 year). Agreement between FD change and PAI change was evaluated using intraclass correlation coefficient (ICC) and Bland–Altman analysis. Categorical agreement between FD- and PAI-based healing classifications was assessed using Cohen’s kappa. Results: FD values showed a significant decrease within the ≤1-year follow-up group (p = 0.049), whereas no significant change was observed beyond 1 year (p = 0.782). Overall FD values demonstrated a decreasing trend from T0 to T1 without statistical significance (p = 0.106). PAI scores decreased significantly in the total sample (p = 0.004). Agreement between FD change and PAI change was negligible (ICC = 0.014; p = 0.466), and categorical agreement was also non-significant (κ = −0.029; p = 0.853). Lower age was independently associated with PAI non-healing (adjusted OR = 0.584 per 1-year increase in age; p = 0.041). Conclusions: FD values exhibited a decreasing trend after RCT, particularly within the first year, supporting reactive bone remodeling toward normal trabecular architecture. The negligible agreement between FD- and PAI-based changes indicates that these measures capture distinct biological dimensions of periapical recovery and should not be considered interchangeable; however, their combined use may provide complementary insights into microarchitectural remodeling and conventional radiographic healing.

Keywords

Supporting Institution

The authors declared that this study has received no financial support.

Ethical Statement

This study was approved by the Iğdır University Non-Interventional Research Local Ethics Committee (Approval No: 2025/22-1).

Pediatrik Hastalarda Endodontik Tedavi Sonrası Periapikal Kemik İyileşmesinin Fraktal Analizi

Abstract

Amaç: Bu çalışmanın amacı, pediatrik hastalarda kök kanal tedavisi (KKT) sonrasında trabeküler kemik yapısındaki değişimleri fraktal analiz (FA) kullanarak nicel olarak değerlendirmek ve bu değişimlerin Periapikal İndeks (PAI) temelli iyileşme ile ilişkisini araştırmaktır. Gereç ve Yöntemler: Çalışmaya ≤16 yaşındaki hastalara ait 41 adet tek köklü anterior diş dahil edildi. Tedavi sonrası hemen alınan (T0) ve takip sürecinde elde edilen (T1) periapikal radyografiler analiz edildi. Fraktal boyut (FD) değerleri standartlaştırılmış ilgi alanlarından hesaplandı. Periapikal iyileşme PAI kullanılarak değerlendirildi ve iyileşmiş (PAI < 3) veya iyileşmemiş (PAI ≥ 3) olarak sınıflandırıldı. Karşılaştırmalar takip süresine göre (≤1 yıl ve >1 yıl) yapıldı. FD değişimi ile PAI değişimi arasındaki uyum intraclass korelasyon katsayısı (ICC) ve Bland–Altman analizi ile değerlendirildi. FD ve PAI temelli iyileşme sınıflamaları arasındaki kategorik uyum Cohen’s kappa yöntemiyle analiz edildi. Bulgular: ≤1 yıllık takip grubunda FD değerlerinde anlamlı bir azalma saptandı (p = 0.049), >1 yıl grubunda ise anlamlı bir değişiklik gözlenmedi (p = 0.782). Genel olarak FD değerleri T0’dan T1’e azalma eğilimi gösterdi, ancak bu fark istatistiksel olarak anlamlı değildi (p = 0.106). Toplam örneklemde PAI skorları anlamlı düzeyde azaldı (p = 0.004). FD değişimi ile PAI değişimi arasındaki uyum ihmal edilebilir düzeydeydi (ICC = 0.014; p = 0.466) ve kategorik uyum da anlamlı bulunmadı (κ = −0.029; p = 0.853). Daha düşük yaş, PAI iyileşmeme durumu ile bağımsız olarak ilişkili bulundu (yaşta her 1 yıllık artış için düzeltilmiş OR = 0.584; p = 0.041). Sonuçlar: FD değerleri KKT sonrasında, özellikle ilk yıl içerisinde, azalma eğilimi göstermiştir; bu bulgu reaktif kemiğin normal trabeküler mimariye doğru yeniden şekillendiğini desteklemektedir. FD ve PAI temelli değişiklikler arasındaki ihmal edilebilir düzeydeki uyum, bu ölçümlerin periapikal iyileşmenin farklı biyolojik boyutlarını yansıttığını ve birbirinin yerine kullanılmaması gerektiğini göstermektedir; ancak birlikte değerlendirildiklerinde mikromimari yeniden yapılanma ile konvansiyonel radyografik iyileşmeye ilişkin tamamlayıcı bilgiler sağlayabilirler.

Keywords

Supporting Institution

Yazarlar bu çalışmanın herhangi bir finansal destek almadığını beyan etmişlerdir.

Ethical Statement

Bu çalışma, Iğdır Üniversitesi Girişimsel Olmayan Araştırmalar Yerel Etik Kurulu tarafından onaylanmıştır (Onay No: 2025/22-1)

References

1. de Oliveira CB, Rocha TG, Pintor AVB, Magno MB, Abrahão AC, Maia LC, et al. Using fractal analysis to assess periapical bone formation after endodontic treatment: a systematic review and meta-analysis. Imaging Sci Dent 2025;55(2):126–138.
2. Akay G, Pamukcu U, Karadag Atas O. Evaluation of the long-term structural change caused by root canal treatment in the bone around the tooth by fractal analysis. Oral Radiol 2025;41(4):498–506.
3. Huang CC, Chen JC, Chang YC, Jeng JH, Chen CM. A fractal dimensional approach to successful evaluation of apical healing. Int Endod J 2013;46(6):523–529.
4. Uğur Aydın Z, Ocak MG, Bayrak S, Göller Bulut D, Orhan K. The effect of type 2 diabetes mellitus on changes in the fractal dimension of periapical lesion in teeth after root canal treatment: a fractal analysis study. Int Endod J 2021;54(2):181–189.
5. Kaya S, Avcı B. Evaluation of the fractal dimension in the apical region of primary teeth with unilateral and bilateral infraocclusion. Cumhuriyet Dent J 2024;27(2):127–135.
6. Yilmaz S, Duzgun S. The quantitative method for following radiologic healing in endodontic retreatment: a 1-year follow-up study. Cumhuriyet Dent J 2023;26(4):367–373.
7. Tosun S, Karataslioglu E, Tulgar MM, Derindag G. Fractal analysis and periapical index evaluation of multivisit nonsurgical endodontic retreatment: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2022;133(2):245–251.
8. Polat Balkan E, Deniz HA, Kurt MH, Samunahmetoğlu E, Karahan S. Application of fractal analysis in detecting trabecular bone characteristics around mandibular impacted third molars on dental panoramic radiographs. Eur Ann Dent Sci 2024;51(2):67–73.

9. Demiralp KÖ, Kurşun-Çakmak EŞ, Bayrak S, Akbulut N, Atakan C, Orhan K. Trabecular structure designation using fractal analysis technique on panoramic radiographs of patients with bisphosphonate intake: a preliminary study. Oral Radiol 2018;35(1):23–28.
10. Chen SK, Oviir T, Lin CH, Leu LJ, Cho BH, Hollender L. Digital imaging analysis with mathematical morphology and fractal dimension for evaluation of periapical lesions following endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(4):467–472.
11. Yu YY, Chen H, Lin CH, Chen CM, Oviir T, Chen SK, et al. Fractal dimension analysis of periapical reactive bone in response to root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107(2):283–288.
12. Bilgin E, Tümen EC. Evaluation of fractal analyses of the trabecular bone region in lesioned and healthy mandibular first permanent molars according to age and gender on panoramic radiographs. Meandros Med Dent J 2024;4:466–480.
13. Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical periodontitis. Dent Traumatol 1986;2(1):20–34.
14. Tosun S, Karataslioglu E, Tulgar MM, Derindag G. Retrospective fractal analyses of one-year follow-up data obtained after single-visit nonsurgical endodontic retreatment on periapical radiographs. Clin Oral Investig 2021;25(11):6465–6472.
15. Aricioglu B, Gunacar DN, Kosar T, Sanal Cikman A, Pertek Hatipoglu F, Maras E. Assessment of bone quality of apical periodontitis treated with MTA plug and regenerative endodontic techniques. Aust Endod J 2022;48(3):444–450.
16. Yildiz B, Dumani A, Isci AS, Sisli SN, Tumani Ustdal B, Yoldas O. Outcome of single-visit root canal treatment with or without MTAD: a randomized controlled clinical trial. Int Endod J 2024;57(1):2–11.
17. Ince Yusufoglu S, Ugur Aydin Z, Tulumbaci F, Bayrak S. Evaluation of different apexification treatments of teeth with immature apices and apical periodontitis on the fractal dimensions of trabecular bone. Aust Endod J 2021;47(2):163–169.
18. Hayek E, Aoun G, Bassit R, Nasseh I. Correlating radiographic fractal analysis at implant recipient sites with primary implant stability: an in vivo preliminary study. Cureus. 2020;12(1):e6689.
19. Karaoğlan F, Miçooğulları Kurt S, Çalışkan MK. Outcome of single- versus two-visit root canal retreatment in teeth with periapical lesions: a randomized clinical trial. Int Endod J 2022;55(8):833–843.
20. Kumar G, Jena S, Manila N, Fareed M, Karobari MI. Incidence of postoperative pain after single-visit and multiple-visit root canal therapy: a systematic review. BMC Oral Health 2025;25(1):47.
21. Xiong B, Hou X, Xia T, Liu Y. Comparison of single-visit versus multiple-visit root canal therapy for chronic anterior apical periodontitis. Am J Transl Res. 2024;16(11):6804-6811.
22. Rao V, Shah AG, Desai EC, Agrawal H, Patel K, Patel P, et al. Outcomes of single-visit versus multi-visit root canal therapy: a meta-analysis of success rates. Eur J Cardiovasc Med 2025;15:62-67.
23. Coşar M, Kandemir Demirci G, Çalışkan MK. The effect of two different root canal sealers on treatment outcome and post-obturation pain in single-visit root canal treatment: a prospective randomized clinical trial. Int Endod J 2023;56(3):318–330.
24. da Silva MEB, dos Santos HS, Ruhland L, Rabelo GD, Badaró MM. Fractal analysis of dental periapical radiographs: a revised image processing method. Oral Surg Oral Med Oral Pathol Oral Radiol 2023;135(5):669-677.
25. Arsan B, Köse TE, Çene E, Özcan İ. Assessment of the trabecular structure of mandibular condyles in patients with temporomandibular disorders using fractal analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123(3):382-391.
26. Zandi H, Petronijevic N, Mdala I, Kristoffersen AK, Enersen M, Rôças IN, et al. Outcome of endodontic retreatment using two root canal irrigants and influence of infection on healing as determined by a molecular method: a randomized clinical trial. J Endod 2019;45(9):1089–1098.
27. Heo MS, Park KS, Lee SS, Choi SC, Koak JY, Heo SJ, et al. Fractal analysis of mandibular bony healing after orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94(6):763-767.

Details

Primary Language

English

Subjects

Paedodontics, Endodontics

Journal Section

Research Article

Authors

Gizem Karagöz Doğan ^*
0000-0001-7798-0738
Türkiye

Yelda Polat Yavuz
0000-0002-3228-3143
Türkiye

Emin Caner Tümen
0000-0002-0905-1096
Türkiye

Publication Date

September 30, 2026

Submission Date

February 2, 2026

Acceptance Date

June 12, 2026

Published in Issue

Year 2026 Volume: 29 Number: 3

DOI

https://doi.org/10.7126/cumudj.1880006

IZ

https://izlik.org/JA26LC63TD

Cite

RIS / Bibtex

APA

Karagöz Doğan, G., Polat Yavuz, Y., & Tümen, E. C. (2026). Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients. Cumhuriyet Dental Journal, 29(3), 433-441. https://doi.org/10.7126/cumudj.1880006

AMA

1.Karagöz Doğan G, Polat Yavuz Y, Tümen EC. Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients. Cumhuriyet Dent J. 2026;29(3):433-441. doi:10.7126/cumudj.1880006

Chicago

Karagöz Doğan, Gizem, Yelda Polat Yavuz, and Emin Caner Tümen. 2026. “Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients”. Cumhuriyet Dental Journal 29 (3): 433-41. https://doi.org/10.7126/cumudj.1880006.

EndNote

Karagöz Doğan G, Polat Yavuz Y, Tümen EC (September 1, 2026) Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients. Cumhuriyet Dental Journal 29 3 433–441.

IEEE

[1]G. Karagöz Doğan, Y. Polat Yavuz, and E. C. Tümen, “Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients”, Cumhuriyet Dent J, vol. 29, no. 3, pp. 433–441, Sept. 2026, doi: 10.7126/cumudj.1880006.

ISNAD

Karagöz Doğan, Gizem - Polat Yavuz, Yelda - Tümen, Emin Caner. “Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients”. Cumhuriyet Dental Journal 29/3 (September 1, 2026): 433-441. https://doi.org/10.7126/cumudj.1880006.

JAMA

1.Karagöz Doğan G, Polat Yavuz Y, Tümen EC. Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients. Cumhuriyet Dent J. 2026;29:433–441.

MLA

Karagöz Doğan, Gizem, et al. “Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients”. Cumhuriyet Dental Journal, vol. 29, no. 3, Sept. 2026, pp. 433-41, doi:10.7126/cumudj.1880006.

Vancouver

1.Gizem Karagöz Doğan, Yelda Polat Yavuz, Emin Caner Tümen. Fractal Analysis of Periapical Bone Healing Following Endodontic Treatment in Pediatric Patients. Cumhuriyet Dent J. 2026 Sep. 1;29(3):433-41. doi:10.7126/cumudj.1880006