Comparative Evaluation of the Accuracy of Two-Dimensional and Three-Dimensional Radiographic Assessment of Bony Defects Before and After Endodontic Surgery

AIM: The aim of this study was to evaluate and compare the accuracy of two-dimensional (2D) and three-dimensional (3D) imaging for the assessment of healing in bony defects before and after endodontic surgery. METHODOLOGY: A total of 92 patients with a history of dental trauma and associated periapical pathology involving the anterior and premolar teeth of the maxilla and mandible were included in the study. Preoperative imaging comprised 2D intraoral periapical radiographs (IOPARs) and 3D cone-beam computed tomography (CBCT) scans of the region of interest. Endodontic surgery was performed in all patients following prior root canal treatment (RCT), and the bony defects were managed using platelet-rich fibrin (PRF). At one-year follow-up, both 2D and 3D imaging were repeated. Lesion area on 2D IOPARs was measured using ImageJ software, whereas volumetric analysis was performed on CBCT images using ITK-SNAP. RESULTS: The mean percentage reduction in lesion area was 91.31% ± 10.14%, whereas the mean volumetric reduction was significantly lower at 78.27% ± 16.00%. Median values were 95.21% (interquartile range (IQR): 15.74%) for area reduction and 75.78% (IQR: 27.18%) for volume reduction. The ranges further highlighted this discrepancy, with area reductions spanning 65.14-100% and volume reductions spanning 37.08-100%. CONCLUSION: While 2D IOPARs are convenient for routine evaluation, they overestimate periapical healing compared with 3D volumetric assessment. CBCT combined with ITK-SNAP provides a more accurate, objective, and clinically reliable evaluation of postoperative bone healing, thereby supporting evidence-based endodontic practice.