The comparison of Cone Beam Computed Tomography and Panoramic radiography for examination of impacted canines. A systematic review

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Kotryna Varnaitė

Fifth Year, Group 14

The comparison of Cone Beam Computed Tomography and

Panoramic radiography for examination of impacted canines.

A systematic review

Master‟s Thesis

Supervisor

Prof,PhD, ArūnasVasiliauskas

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FINAL MASTER‘S THESIS IS CONDUCTED

AT THE DEPARTMENT OF ORTHODONTICS

STATEMENT OF THESIS ORIGINALITY

I confirm that the submitted Final Master„s Thesis „The comparison of Cone Beam Computed Tomography and Panoramic radiography for examination of impacted canines. A systematic review“

1. Is done by myself.

2. Has not been used at another university in Lithuania or abroad.

3. I did not used any additional sources that are not listed in the Thesis, and I provide a complete list of references.

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Kotryna Varnaite

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Arūnas Vasiliauskas

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Final Master‘s Thesis reviewer

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Evaluation of Final Master‘s Thesis Defense Board:

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF ODONTOLOGY CLINIC OF ORTHODONTICS

The comparison of Cone Beam Computed Tomography and Panoramic radiography for examination of impacted canines. A systematic review

Master‟s Thesis

The thesis was done by student: Supervisor:

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SUMMARY

Objectives: The purpose of this systematic review was to evaluate and compare cone beam computed tomography (CBCT) use versus panoramic radiographs in the maxillary impacted canine examination.

Materials and Methods: Systematic search for articles was done in the databases: PubMed, Cochrane Library and EBSCO publishing. Publishing year for articles searched was between 2015 and 2020. Articles included studies on humans published in English.

Results: Initial search was done and a total of 702 articles were detected. After duplications were removed 426 articles were reviewed and after application of inclusion and exclusion criteria, 5 articles were selected for the systematic review.

Conclusion: Panoramic radiograph is good enough for impacted maxillary canine examination, and although cone beam computed tomography (CBCT) is superior in some aspects it is still not necessary in a routine examination.

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1. INTRODUCTION

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11 two-dimensional (2D) examinations. Different CBCT scan equipment was used and study radiation variedfrom 15 times higher dose to 140 times higher dose than two-dimensional radiographs [13]. Some companies are stating that their CBCT scan machines radiation dose only 6 times higher than panoramic radiograph and can be used as a routine radiographic examination instrument. However the clinical recommendations bythe American Academy of Oral and Maxillofacial Radiologystate that CBCT use supposed to be justified, because of the patients risk to high radiation dose [14]. It is important to analyse researches up to this date that compares panoramic radiographs and CBCT use in the examination of impacted maxillary canines and to see if CBCT scan should be used as routine examination or conventional panoramic radiographs is enough. Therefore, this systematic research aims to compare CBCT use versus panoramic radiographs in the impacted maxillary canine examination in the studies presented from 2015 to this date.

Aim:

The aim of this review is to compare panoramic radiographs versus cone-beam computed tomography scans in the examination of impacted maxillary canines.

Tasks:

 To compare panoramic radiographs and CBCT scans at detecting adjacent tooth root resorption.

 To asses if there is an agreement of impacted canine sector position between panoramic radiographs and CBCT scans.

 To estimate which examination method panoramic radiographs or CBCT scans is superior to determine labio-palatal position of the impacted canine.

Hypothesis:

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2. SEARCH METHODS AND STRATEGY

The focus question was developed by using the population, intervention, comparison, and outcome study design which is presented in Table 1.

Table 1. PICO table

Population(P) Patients with maxillary impacted canines.

Intervention(I) Radiographic diagnostics of impacted maxillary canines

Comparison(C) Comparison of 2-dimensional radiograph images and CBCT scan images.

Outcome(O) Superior CBCT scan images than 2 dimensional radiographs in the examination of impacted maxillary canines

Focus question Does the CBCT radiographs should be used in the routine examination of impacted maxillary canines?

Bioethics approval:

This systematic review was approved by LUHS bioethics centre. Approval code BEC-OF(U)-127

Types of publications:

The systematic review included studies on humans published in the English language.

Types of studies:

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Population:

Patients who had an examination of impacted maxillary canines done by 2-dimensional and 3-dimensional imaging.

Information Sources:

Information and articles collected from PubMed, Cochrane Library and EBSCO publishing.

Literature search strategy and screening:

To detect eligible articles systematic search was done in three different databases: PubMed, Cochrane Library and EBSCO publishing. According to the inclusion and exclusion criteria, suitable studies were selected. Various keyword combinations were used and Table 2 shows results found. Figure 1 is representing the whole process for article selection with the use of PRISMA flow chart.

Table 2. Keyword combinations and results

Keyword combination Results Search date

“Impacted canines”

“Impacted canines”, “CBCT”

“Impacted canines”, “Cone beam computed tomography” “Impacted canines”, “conventional radiography”

“Impacted canines”, “panoramic radiography” “Impacted canines”, “x-ray”

“Impacted canines”, “3D imaging”

“Impacted”, “3 dimensional imaging”, “2 dimensional imaging”

“Impacted canines”, “CBCT”, “panoramic radiography”

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Inclusion and exclusion criteria:

Inclusion criteria

 Studies only onhumans

 Articles in the English language

 Articles published between 2015 and 2020

 Observational cross-sectional studies, randomized clinical trials or cohort studies.

Exclusion criteria

 Literature reviews, case reports  No full text, no access

 Animal studies

Selection of studies:

After the initial search was done and duplicates removed, article screening performed by checking titles and abstracts also applying inclusion and exclusion criteria. Articles selected after the

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Assessment of bias risk

The risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale modified for cross-sectional studies for the systematic review (Annex 1). All studies were classified as low risk and high quality. The results are shown in Table 3.

Table 3. Risk of bias assessment according to Newcastle Ottawa Scale

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3. SYSTEMIZATION AND ANALYSIS OF DATA

Five observational – cross sectional studies were selected for this review. Articles were examined exhaustively and all the main features of the studies gathered and compered (Table 4).

Table 4. Characteristics of the qualified studies in this systematic review

Author years

Sample size

Study design Imaging systems Examiners Imaging

parameters for CBCT system Björksved et al 2019 58 patients (64 impacted canines) Observational –cross sectional panoramic x-ray CBCT 2 radiologists kV: 85 or 120 mA: 5-7 or 5 Scan time: 17.5sec or 8.9sec FOV: 6 x 6 cm or 16 x 3.8cm Tsolakis et al 2018 20 patients Observational –cross sectional periapical, occlusal, panoramic x-rays CBCT 3 orthodontists NewTomVG1(QR, Verona, Italy) (no parameters provided) Ngo et al 2018 64 patients(8 4 impacted canines) Observational –cross sectional panoramic x-ray CBCT 2 (profession not mentioned) kVp: 120 mA: 5 Scan time: 17.8s FOV: 23 x 17 cm Pico et al 2017 20 patients (28 impacted canines) Observational –cross sectional panoramic x-ray CBCT 9 orthodontists kV: 120 mA: 5 Scan time: 4s FOV: 100 Kim et al 2017 104 patients( 104 impacted canines) Observational –cross sectional panoramic x-ray CBCT 1 (profession not mentioned) kVp: 90 Scan time: 24 s mA: 4 FOV: 10 x 8 cm

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3.1 Evaluation of panoramic radiographs versus cone beam computed tomography scans in the detection of the root resorption

Root resorption is one of the criteria‟s why CBCT is used in the examination of the maxillary impacted canines. The following studies are comparing panoramic radiographs versus CBCT images in the detection of the adjacent tooth root resorption (Table 5)

Table 5. Data of root resorption detection

Authors Outcome variables Results

Tsolakis et al 2018

Interobserver agreement Unweighted overall kappa = 0.67

Ngo et al 2018

Intraobserver agreement

Interobserver agreement

Cohen weighted kappa = 1 p<0.001

Cohen weighted kappa = 0.883 p<0.001

Pico et al 2017

Intermodalities agreement between 2 groups

Cohen weighted kappa = 0.105 p=0.015

In the Tsolakis study three conventional radiographic methods (panoramic, occlusial and periapical) were compared with the CBCT scans, which were used as a golden standard. Sample of 20 patients between ages 10 to 17 years was selected. CBCT scans for the patients were done after the radiographic examination, to give more information and confirm potential root resorption. Three examiners with at least 15 years of experience, evaluated images for the detection of the adjacent tooth root resorption. For interobserver agreement, unweighted kappa was used, which allows to evaluate pairwise agreement. Overall unweighted kappa for panoramic images compared to CBCT scans was k=0.67, which means that agreement is good.

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19 included in the study were supposed to be done not more than 6 months apart. A comparison of the CBCT and panoramic volumes was done by two examiners. Intraobserver agreement for the root resorption was perfect k=1 (p<0.001) and interobserver agreement was high as well k=0.8833 (p<0.001).

In the study carried out by Pico patients were selected according to inclusion criteria. Twenty patients between the age of 13 to 73 (50% males, and 50 % females) with 28 impacted maxillary canines were selected and data collected and examined. Two groups of images were present: group A- panoramic image and group B- three-dimensional CBCT images. Postgraduate orthodontists were picked as examiners for this research, groups were compared for the root resorption and Cohen weighted kappa = 0.105 (p=0.015) results showedpoor agreement.

3.2 Agreement evaluation of impacted canine sector position between panoramic radiographs and cone beam computed tomography scans

Table 6 represents studies where panoramic and CBCT images were divided into sectors.

Table 6. Data if impacted canine sector position

Björksved et al 2019

Total agreement Cohen weighted kappa = 0.36

Ngo et al 2018

Intraobserver agreement Interobserver agreement

Cohen weighted kappa = 0.9054 p<0.001 Cohen weighted kappa = 0.9054 p<0.001

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20 Björksved et al. conducted research by collecting data for analysis from 2 orthodontic centers in Sweden. Participants in the study had to meet the inclusion criteria. 58 participants, 21 boys with mean age 13.4 and 34 girls with mean age 13.2, who had panoramic and CBCT images done were selected. A total number of sixty-four impacted canines were examined, from which 52 was unilateral and 6 was bilateral impaction. Panoramic radiographs and CBCT images were divided into sectors. Panoramic radiographs and CBCT images were compered for the sector location agreement, Cohen weighted kappa = 0.36, meaning it was a fair agreement.

Ngo panoramic images divided into 5 sectors. The values of the panoramic and CBCT images were reviewed twice in one month interval to establish interobserver and intraobserver agreement. Both agreement results were high. Intraobserver agreement for the sector locationCohen weighted kappa = 0.9054 (p<0.001) and Interobserver agreement for the sector location Cohen weighted kappa = 0.9054 (p<0.001).

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3.3 Evaluation of panoramic radiographs versus cone beam computed tomography scans in the detection of labio-palatal impacted canine position

Discovering impacted canines position during radiographic examination is important when deciding treatment options. Studies presented in Table 7 compare panoramic radiographs and CBCT images in labio-palatal canine position detection.

Table 7. Data of labio-palatal canine position detection

Ngo et al 2018

Intraobserver agreement Cohen weighted kappa = 1 p<0.001

Pico et al 2017

Intrarater agreement Cohen weighted kappa = 0.271 p<0.001

Kim et al 2017 Intraexaminer agreement Cohen weighted kappa = 0.834 p<0.001

Ngo et al. research also assessed labio-palatal location of the impacted maxillary canines. All panoramic and CBCT images had no patients data on them and were displayed in random order for the examination. There were no interobservers results stated and intraobserver agreement was perfect with Cohen weighted kappa = 1 (p<0.001)

In Pico et al. study 9 orthodontists examined panoramic images and CBCT images. Questionnaires were given to the examiners with ten different topics to analyse. First topic was about localization and the position of the impacted canine. Intrarater agreement for the labio-palatal position was given and Cohen weighted kappa = 0.271 (p<0.001) showed significantly poor agreement.

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4. DISCUSSION

In this systematic review two different radiographic examination methods were compered. CBCT scans and panoramic radiographs were assessed and compared to see which is superior in the examination of the impacted maxillary canines. A lot of studies were done to compare these two methods to see if conventional radiography is good enough and if CBCT use is necessary.

Adjacent tooth root resorption is one of the main reasons why CBCT scans are used for the examination. In the study done by Tsolakis et al. interobserver agreement for root resorption was Unweighted overall kappa = 0.67, which means the agreement is good, however, the authors concluded that CBCT is more accurate and precise in the detection of the root resorption [15]. In the study performed by Ngo et al. comparison of the CBCT and panoramic volumes was done by two examiners. Panoramic images were divided into sectors and concluded that sector location in the panoramic images might help to predict root resorption. Intraobserver agreement for the root resorption was perfect k=1 (p<0.001) and interobserver agreement was high as well k=0.8833 (p<0.001) [16]. However, in the study done by Pico et al. the agreement between panoramic and CBCT images was very poor with Cohen weighted kappa = 0.105 (p=0.015). Authors stated that CBCT images had very different observations from panoramic images when examiners evaluated roots resorption present or not. Researchers concluded that 3D images provided better results in root resorption detection [17].

The results showed opposed opinions, which method is superior and if CBCT is necessary for root resorption detection. Comparing this review‟s result with studies performed before 2015, Alqerban et al. and Botticelli et al. concluded that values of root resorption detection were higher in CBCT images [5,18].

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23 A similar study to the described above with the sector locations by Alessandri method was done by Kim et al. in 2017. Intraexaminer agreement was a high kappa value of 0.824 (p<0.001) for the sector location [20].

All studies concluded that panoramic radiograph is good enough and CBCT use should be highly considered. Ngo et al. stated that dividing panoramic images into sectors increases its accuracy and Kim et al. concluded that sector location on the panoramic radiographs can help early detection of the impacted maxillary canines [16,19,20]. The similar results appeared in the studies performed before 2015. Jung et al. used the same sector location as in Ngo et al study and concluded that sectors increased panoramic radiograph abilities detecting impacted canine teeth and its position [21]. Where in the study done by Warford et al. different sector location was used, however, authors came to the same conclusion that sectors helped for panoramic x-ray evaluation and the use of CBCT is not crucial [22].

The first step of the impacted canine examination is localization. When inspecting impacted canines position, usually three orthogonal planes are considered. It is tremendously important to assess position and inclination for the treatment planning, duration and prognosis. It is essential to know labio-palatal position for later surgical exposure. In the study done by Pico et al. results were completely opposite to the other two researches. Intrarater agreement for the labio-palatal position showed Cohen weighted kappa = 0.271 (p<0.001) and authors stated that agreement was statistically significantly poor [17]. As all of the values above presented by Ngo et al. labio-palatal position comparing CBCT scan and radiographic x-ray had high intraobserver agreement, Cohen weighted kappa = 1 (p<0.001) and results were statistically significant [16]. For the labio-palatal position evaluation in the study by Kim et al. intraexaminer agreement was high as well, with a kappa value of 0.834 results being statistically significant [20].

The explanation for these results might be that studies by Ngo et al. and Kim et al. had sector location on the panoramic images and it might help to evaluate position better, but further studies should be done to see if it is related.

As for the study performed before 2015, Haney et al. stated had a high 84% agreement was found for the labio-palatal position and that there was no statistically significant difference between 2D and 3D methods. Pico et al. study had no sector locations and got opposite results [23]. Overall results show that a panoramic radiograph is reliable to determine labio-palatal position. Although studies with a bigger sample size should be done in the future.

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24 different opinions. Alqerban et al. concluded that agreement was strong, where in the study by Botticelli et al. treatment plan with 2D or 3D analysed data differed [18, 24].

In addition, we should mention that all studies used different CBCT scans and panoramic radiographs manufactures and it might have some impact on the results obtained. Also, research had different methodologies, the sample size that might have an effect as well. Comparing the overall result of this study, all three tasks presented quite high agreement between CBCT and panoramic radiographs. Although more studies with larger samples and different observations should be done in the future.

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5. CONCLUSSION

1. Cone beam computed tomography scans and panoramic radiographs images had similar results in the detection of adjacent tooth root resorption.

2. There was the agreement for sector location between panoramic radiographs and cone beam computed tomography scans.

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6. PRACTICAL RECOMMENDATIONS

According to this systematic review panoramic radiograph is good enough for the examination of the impacted maxillary canines. For the treatment planning important role play detection of root resorption ether for adjacent tooth or canine itself, therefore if radiographic images arises the question of presence or absence of root resorption CBCT scan should be used for examination. Inspection of the panoramic radiographs and CBCT scans may depend on the orthodontist

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7. REFERENCE

1. Stewart JA, Heo G, Glover KE, Williamson PC, Lam EW, Major PW. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop2001;119:216-25.

2. Fernandez E, Bravo L A, Canteras M. Eruption of the permanent upper canine: a radiologic study. Am J Orthod Dentofacial Orthop 1998;113: 414–420

3. Mazinis, E., Zafeiriadis, A., Karathanasis, A. Lambrianidis T. Transmigration of impacted canines: prevalence, management and implications on tooth structure and pulp vitality of adjacent teeth. Clin Oral Invest (2012) 16:625–632

4. Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000;70:415–423

5. Alqerban A, Jacobs R, Fieuws S, Willems G. Comparison of two cone beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root resorption. Eur J Orthod 2011;33:93–102.

6. Rossini G, Cavallini C, Cassetta M, Galluccio G, Barbato E. Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature. Ann Stomatol (Roma) 2012;3:14–8.

7. Sarıkır Ç, Toraman Alkurt M, Değerli Ş, Altunkaynak B, Peker İ. Comparison of panoramic radiography and conebeam computed tomography for qualitative and quantitative measurements regarding localization of permanent impacted maxillary canines. Acta Odontol Turc 2017;34(1):1-7

8. Suomalainen A, Pakbaznejad Esmaeili E, Robinson S. Dentomaxillofacial imaging with panoramic views and cone beam CT. Insights Imaging (2015) 6:1–16

9. Scarfe WC, Azevedo B, Toghyani S, Farman AG. Cone Beam Computed Tomographic imaging in orthodontics. Aust Dent J. 2017 Mar;62 Suppl 1:33-50.

10. Nemtoi A, Czink C, Haba D, Gahleitner A. Cone beam CT: a current overview of devices. Dentomaxillofac Radiol 2013; 42: 20120443.

11. Kumar M, Shanavas M, Sidappa A, Kiran M. Cone beam computed tomography - Know its secrets. J Int Oral Health 2015;7(2):64-68.

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28 13. Kadesjö N, Lynds R, Nilsson M, Shi X-Q. Radiation dose from X-ray examinations of impacted canines: cone beam CT vs two-dimensional imaging. Dentomaxillofac Radiol 2018; 47: 20170305.

14. Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Aug;116(2):238-57

15. Apostolos I. Tsolakis, Michael Kalavritinos, Elias Bitsanis, Mattheos Sanoudos, Vassiliki Benetou, Konstantina Alexiou, et al. Reliability of different radiographic methods for the localization of displaced maxillary canines. Am J Orthod Dentofacial Orthop 2019;155:380-7 16. Ngo CTT, Fishman LS, Rossouw PE, Wang H, Said O. Correlation between panoramic

radiography and cone-beam computed tomography in assessing maxillary impacted canines. Angle Orthod. 2018;88:384–389

17. Pico CL, do Vale FJ, Caramelo FJ, Corte-Real A, Pereira SM. Comparative analysis of impacted upper canines: Panoramic radiograph Vs Cone Beam Computed Tomography. J Clin Exp Dent. 2017;9(10):e1176-82.

18. Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two- versus three-dimensional imaging in subjects with unerupted maxillary canines. Eur J Orthod. 2011 Aug;33(4):344-9 19. Björksved M, Magnuson A, Bazargani SM, Lindsten R, Bazargani F. Are panoramic

radiographs good enough to render correct angle and sector position in palatally displaced canines? Am J Orthod Dentofacial Orthop 2019;155:380-7

20. Kim SH, Son WS, Yamaguchi T, Maki K, Kim SS, Park SB, at al.. Assessment of the root apex position of impacted maxillary canines on panoramic films.Am J Orthod Dentofacial Orthop 2017;152:489-93

21. Jung YH, Liang H, Benson BW, Flint DJ, Cho BH. The assessment of impacted maxillary canine position with panoramic radiography and cone beam CT. Dentomaxillofac Radiol. 2012 Jul;41(5):356-60

22. Warford JH Jr, Grandhi RK, Tira DE. Prediction of maxillary canine impaction using sectors and angular measurement. Am J Orthod Dentofacial Orthop 2003;124:651-5

23. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ, et al. Comparative analysis of traditional radiographs and cone-beam computed tomography volumetric images in the diagnosis and treatment planning of maxillary impacted canines. Am J Orthod Dentofacial Orthop 2010;137:590-7

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8. ANNEXES

Annex 1

NEWCASTLE - OTTAWA QUALITY ASSESSMENT SCALE (adapted for cross-sectional studies)

Selection: (Maximum 3 stars)

1) Representativeness of the sample:

a) Truly representative of the average in the target population. (all subjects or random sampling)

b) Somewhat representative of the average in the target population. (non-random sampling)

c) Selected group of users.

d) No description of the sampling strategy. 2) Non-respondents:

a) Comparability between respondents and non-respondents characteristics is established, and the response rate is satisfactory. 

b) The response rate is unsatisfactory, or the comparability between respondents and non-respondents is unsatisfactory.

c) No description of the response rate or the characteristics of the responders and the non-responders.

3) Ascertainment of the exposure (risk factor): a) Validated measurement tool. 

b) Non-validated measurement tool, but the tool is available or described. c) No description of the measurement tool.

Comparability: (Maximum 2 stars)

1) The subjects in different outcome groups are comparable, based on the study design or analysis. Confounding factors are controlled.

a) The study controls for the most important factor (select one).  b) The study control for any additional factor. 

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Outcome: (Maximum 2 stars)

1) Assessment of the outcome:

a) Independent blind assessment.  b) Record linkage. 

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30 2) Statistical test:

a) The statistical test used to analyze the data is clearly described and appropriate, and the measurement of the association is presented, including confidence intervals and the probability level (p value). 

b) The statistical test is not appropriate, not described or incomplete.

The comparison of Cone Beam Computed Tomography and Panoramic radiography for examination of impacted canines. A systematic review

Kotryna Varnaitė