Evaluation of the effect of overhanging restored teeth on alveolar bone by retrospective comparative fractal analysis

Abstract

Background

It is important to recognize that overhanging restorations can have adverse effects on the alveolar bone. The objective of this study was to evaluate the alterations in the bone surrounding teeth with overhanging restorations on digital panoramic radiographs (DPRs) employing fractal analysis (FA).

Methods

A total of 800 DPRs were examined, and 123 teeth presenting with overhanging restorations were identified. The alveolar bone structure around these teeth was analysed along with unrestored areas for comparison. FA was used to evaluate of the DPRs using the box-counting method. The statistical significance level was accepted as p < 0.05.

Results

The study revealed that fractal dimension (FD) values were significantly lower in areas with overhanging restorations compared to healthy areas (p < 0.001). The analysis revealed that teeth exhibiting signs of overhanging restorations were predominantly located in quadrant 1 (35.8%, n = 44). The analysis revealed that 74.8% of these teeth were molars (n = 92) and 25.2% were premolars (n = 31). The statistical analysis revealed that there was no statistically significant difference in the FD of premolar and molar teeth with overhanging restoration (p > 0.05).

Conclusions

The FD data indicate that overhanging restorations may adversely affect the trabecular structure of the alveolar bone. This finding suggests that careful attention to margin alignment during restorative procedures may be beneficial for the preservation of alveolar bone health.

Introduction

Amalgam has been a widely preferred material for the restoration of caries in posterior teeth for many years [1]. Following the introduction of adhesive dental materials by Buonocore, minimally invasive restorative approaches have been adopted in dentistry [2, 3]. During restorative procedures, it is imperative to ensure proper interproximal contact to maintain tooth position, ensure stability and improve cleanability [4]. However, overhanging restorations are among the physician-related errors that exceed the cavity boundaries and disrupt the anatomical form of the restoration [5]. Morphological variations (furcations, concave structures, grooves) in the collar region of the tooth can impede the placement of the matrix band, potentially leading to incomplete filling of the gingival cavity and the subsequent formation of overhanging restorations [6]. Although overhanging restorations are most commonly observed on the proximal surfaces of posterior teeth, they have the capacity to occur on any tooth surface [7].

In relation to the impact on periodontal health, overhanging restorations have been shown to result in increased plaque and debris accumulation, which complicates surface cleaning and alters the composition of the periodontal microflora. It is conceivable that the consequence of this could be damage to interdental septa, deepening of periodontal pockets and alveolar bone resorption [8, 9]. A substantial body of research has concluded that plaque accumulation is higher, gingivitis is observed more frequently and periodontal losses are more pronounced in areas with overhanging restoration [10].

In particular, as has been reported, the extension of proximal restorations to subgingival margins may result in the triggering of an inflammatory reaction in adjacent periodontal tissues [11]. As indicated by numerous sources, a strong correlation has been demonstrated between the extent of overflow and the progression of periodontal deterioration. It has been determined that even minor occurrences of overflow have the potential to augment an individual’s vulnerability to the accumulation of placa and the resurgence of recurrent caries [12, 13].

Digital panoramic radiographs (DPRs) are a widely utilised imaging modality within the field of dentistry. They function as an effective tool for the monitoring of bone changes, in addition to serving as a general evaluative modality for both jaw bones and teeth [14, 15]. In this evaluation process, fractal analysis (FA) is a prominent method that is both economical and accessible. It allows for the estimation of alveolar bone density and the distinction of osteoporotic changes with data obtained from dental radiographs [15, 16].

Furthermore, the results of the present meta-analysis indicate that fractal analysis is most commonly performed on DPRs. This method is identified as the primary imaging modality preferred for the evaluation of trabecular bone structure in the relevant literature [17]. Furthermore, Magat et al. [18] in their study comparing digital panoramic radiograph (DPR) with cone beam computed tomography (CBCT) stated that CBCT has disadvantages such as higher radiation dose and lower image resolution; therefore, they emphasised that DPRs may be a more appropriate option for trabecular bone evaluation.

It is well established that overhanging restorations have a detrimental effect on periodontal health. Numerous studies have demonstrated an association between overhanging restorations and the accumulation of plaque, gingival inflammation and periodontal destruction [5–9, 11]. However, the specific effects of these restorations on alveolar bone density have received relatively little attention. There is also a lack of studies that evaluate bone density and structural changes using noninvasive, objective methods, such as FA [19, 20]. Consequently, it is challenging to reach a definitive conclusion regarding the impact of overhanging restorations on alveolar bone.

The objective of the present study was to evaluate alterations in alveolar bone morphology in teeth with overhanging restorations by means of the FA method, utilising a DPRs. The null hypothesis posits that the FD measured in the overhanging restoration areas is not statistically significantly different from the FD measured in the control group areas.

Materials and methods

Ethical approval and study initiation

The present study was initiated with the approval of Niğde Ömer Halisdemir University Non-Interventional Clinical Research Ethics Committee (Ethics Approval No: 2023/42). The research is being conducted in accordance with the ethical principles set out in the Declaration of Helsinki. Given the retrospective nature of our study, the ethics committee deemed the informed consent form to be exempt.

Study scope and participants

The present study was meticulously planned to encompass patients within the age range of 18 to 40 years who submitted applications to Niğde Ömer Halisdemir University Faculty of Dentistry Oral and Dental Health Practice Centre for dental treatment during the period spanning from January 2023 to June 2024. No additional X-rays were obtained from the patients for the purposes of this study. The evaluation was conducted on DPRs obtained for diagnostic purposes.

A priori power analysis was conducted in order to ascertain the number of units to be included in the study. To perform the power analysis, the findings of Büyükgöze Dindar et al. [19] were taken as a point of reference. Accordingly, it was determined that the study should be conducted with a minimum sample size of 74 individuals, based on a designed sample size calculation in which the effect size was accepted as d = 0.602, the type I error was accepted as 5%, and the statistical power was accepted as 80%. The relevant analysis was performed using the G*Power 3.1.9.7 program. The RStudio 2024.12.0 program was utilised to generate the graphs. The statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 25.0 (released 2017 by IBM Corp.). The significance level was set at p < 0.05 (α).

Data collection and inclusion criteria

DPRs, sociodemographic information and medical history of eligible patients were obtained from the dental automation system. However, only posterior teeth with a overhanging restoration on one proximal surface on DPRs of sufficient diagnostic quality were included in the study. A total of 800 DPRs were evaluated, and 123 teeth with overhanging restorations were identified. However, only one tooth with an overhanging restoration from a DPR was included in the study.

Exclusion criteria

The exclusion criteria encompassed inadequate recorded radiological data, poor diagnostic quality, bone mineralisation disorders due to local or systemic diseases, a history of drug use affecting bone metabolism, the presence of any lesion in the relevant area and the presence of missing teeth adjacent to the tooth being evaluated. Furthermore, it was necessary that the individuals included in the study should have a minimum of 20 teeth in their mouths, with the exception of third molars.

Dental panoramic radiography protocol

In accordance with the manufacturer’s protocol, all DPRs were obtained by the same technician using the PLANMECA ProMax DIMAX 2 instrument (Helsinki, Finland). The imaging procedure was conducted utilising a voltage of 66 kVp, an current of 8 mA, and an exposure time of 15.8 s. It is evident that all Digital Rights Management (DRM) records were captured at a resolution of 2490 × 1435 pixels and in Tagged Image File Format (TIFF). The diagnosis of overhanging restoration on DPRs was made by a specialist in restorative dentistry, who has accrued six years of clinical experience. An oral and maxillofacial radiologist with 11 years of experience performed the FA assessment in a semi-dark, quiet room. In order to assess the reliability of the intra-observer analysis, 20% of the radiographs were subjected to re-analysis at two-weeks apart for the purpose of overhanging restoration detection and FA.

Overhanging restoration diagnostics

The present study sets out the following diagnostic criteria for determining overhanging restorations: the end edge of the restoration must be 0.5 mm or more away from the proximal tooth surface [21]. Consequently, surfaces with overhanging restorations are categorised as the “overhanging side” (OH) category. Conversely, the side of the tooth that is free of restoration and caries on radiographs is considered “nonoverhanging side” (NS).

Fractal analysis

Selected areas were analyzed using ImageJ v.1.48 software (US National Institutes of Health, Bethesda, MD; https://imagej.nih.gov/ij/). FD was calculated by the method of White and Rudolph [22]. Two rectangular regions of interest (ROI) measuring 20 × 80 pixels were selected for fractal analysis. Two ROIs were selected for fractal analysis, one from the alveolar bone in OH and one from the interdental alveolar bone in NS (Fig. 1). The ROI was determined to include the largest area from the OH and NS of the teeth to the adjacent trabecular bone. It was ascertained that the designated regions ROIs did not coincide with the anatomical structures of adjacent teeth, including the lamina dura, the inferior sinus, the alveolar canal borders, and/or the maxillary sinus [23]. The selected ROI was duplicated, and the following steps were applied in order: Gaussian Blur, Make Binary, Erode, Dilate, Invert, Skeletonize, and Fractal Box Counter. The FD values were then calculated.

Fig. 1.

Panoramic radiograph showing two selected regions of interest (ROIs); (A) ROI-2 represents the nonoverhanging (control) area, (B) ROI-1 represents the overhanging area

Statistical analysis

The Shapiro-Wilk test was employed to ascertain the normality assumption of the variables. The descriptive statistics of the demographic information are presented as the number (n) and percentage (%). In instances where the normality assumption was not met in the comparison of two groups, the Mann-Whitney U test was employed. For comparisons involving more than two groups, the Kruskal-Wallis H test was utilized. The Wilcoxon sign test was employed when the normality assumption was not met in the context of comparing two dependent groups. The Spearman correlation test was employed to ascertain the relationship between measurement values that were non-normally distributed. The inter-observer reliability analysis was assessed using both Cohen’s kappa coefficient for categorical variables and correlation analysis for continuous variables.

Results

In the inter-observer reliability analysis, Cohen’s kappa coefficient was 0.82 for categorical variables and the intraclass correlation coefficient (ICC), which evaluates internal consistency, was 0.91 for continuous variables. The findings suggest that the measurements are highly reliable [24, 25].

54.5% of the patients were female (n = 67) and 45.5% were male (n = 56) and the mean age of the patients was 33.54 ± 8.86 years. An examination of the distribution of teeth with overhanging restorations according to quadrants reveals that the highest rate is observed in quadrant 1 (n = 44), with 35.8% of cases exhibiting this characteristic. This is followed by quadrant 2 (n = 31) with 25.2%, quadrant 3 (n = 30) with 24.4% and quadrant 4 (n = 18) with 14.6%, respectively. The present investigation revealed that 74.8% of the overhanging restorations were molars (n = 92) and 25.2% were premolars (n = 31). When the distribution according to age groups is analyzed, it is seen that 41.5% of the patients with overhanging restoration are 36 years and older (n = 51), 34.1% are between 26 and 35 years (n = 42) and 24.4% are between 15 and 25 years (n = 30) (Table 1).

Table 1.

Distribution of demographic characteristics of the individuals included in the study

Variable	Frequency (n)	%
Gender
• Female	67	54.5
• Male	56	45.5
Quadrant
• 1	44	35.8
• 2	31	25.2
• 3	30	24.4
• 4	18	14.6
Location
• Molar	92	74.8
• Premolar	31	25.2
Tooth number
• 14–17	43	35.0
• 24–27	31	25.2
• 34–37	30	24.4
• 44–47	19	15.4
Age
• 15–25	30	24.4
• 26–35	42	34.1
• 36 and over	51	41.5

FD values were significantly higher in NS compared to OH (p < 0.001). The mean FD was 0.97 ± 0.08 in OH and 0.99 ± 0.08 in NS, while the median value was 0.99 in both groups. In molar teeth, the FD in OH were found to be significantly lower than in NS, with a median of 0.99 and a mean of 0.98 ± 0.07 (p = 0.031). The difference was more pronounced in premolars, where FD in OH was significantly higher than in NS (p < 0.001) (Table 2).

Table 2.

Comparison of fractal dimension in overhanging side and fractal dimension in nonoverhanging side within groups according to tooth positions

Variable	Overhanging side		Nonoverhanging side		pc value
	Median(Min.:Max.)	Mean ± SD	Median(Min.:Max.)	Mean ± SD
FD (n = 123)	0.99(0.87:1.20)	0,97 ± 0,08	0.99(0.90:1.30)	0.99 ± 0.08	< 0,001*
M-FD (n = 92)	0.99(0.87:1.20)	0,98 ± 0,07	0.99(0.90:1.30)	0.99 ± 0.07	0.031*
PM-FD (n = 31)	0.90(0.87:1.20)	0.97 ± 0.10	0.99(0.90:1.30)	1.01 ± 0.11	< 0,001*

p < 0.05 significance level

FD Fractal Dimension, SD Standard Deviation, c Wilcoxon Sign test, PM Premolar, M Molar

A statistically significant discrepancy between male and female subjects was not observed in regard to FD in OH (p > 0.05). The statistical analysis revealed no statistically significant difference between the quadrants in terms of FD in OH (p > 0.05). However, it has been demonstrated that the median and mean values in quadrants 1 and 2 are greater than those in Quadrants 3 and 4. The statistical analysis revealed no statistically significant differences in FD in OH among premolar and molar teeth (p > 0.05). Conversely, the investigation revealed no statistically significant disparities in terms of FDs among the various age demographics within OH (p > 0.05). A statistically significant discrepancy between male and female was not observed in the NS cohort with respect to FD (p > 0.05). Following a thorough examination of the available data, it was determined that there was no statistically significant difference between the quadrants in terms of FDs in NS (p > 0.05). The statistical analysis revealed no substantial difference in the mean FD of premolars and molars in NS (p > 0.05). In addition, a determination was made that there was no statistically significant difference between age groups in terms of FD in NS (p > 0.05) (Table 3).

Table 3.

Comparison of fractal dimension in nonoverhanging side and fractal dimension in overhanging side between demographic characteristics, quadrant and tooth position variables

Variable	FD in nonoverhanging side		p value	FD in overhanging side		p value
	Median (Min.-Max.)	Mean ± SD		Median (Min.-Max.)	Mean ± SD
Gender
• Female	0.99(0.90:1.30)	0.99 ± 0.07	0.953a	0.99(0.87:1.20)	0.97 ± 0.07	0.692a
• Male	0.99(0.90:1.30)	0.97 ± 0.09		1(0.87:1.20)	0.99 ± 0.09
Quadrant
• 1	0.99(0.90:1.30)	0.99 ± 0.08	0.100b	1(0,87:1,20)	0,99 ± 0,08	0.085a
• 2	1.01(0.90:1.30)	1.02 ± 0.11		1(0,87:1,20)	1,00 ± 0,09
• 3	0.95(0.90:1.07)	0.97 ± 0.04		0,93(0,87:1,06)	0,96 ± 0,07
• 4	0.96(0.90:1.19)	0.98 ± 0.07		0,92(0,87:1,06)	0,94 ± 0,06
Location
• M	0.99(0.90:1.30)	0.99 ± 0.07	0.988a	0.99(0.87:1.20)	0.98 ± 0.07	0.273a
• PM	0.99(0.90:1.30)	1.01 ± 0.11		0.90(0.87:1.20)	0.97 ± 0.09
Age
• 15–25	0.98(0.90:1.11)	0.98 ± 0.05	0.676b	0.98(0.87:1.10)	0.96 ± 0.07	0.682b
• 26–35	0.98(0.90:1.30)	0.99 ± 0.07		0.99(0.87:1.20)	0.97 ± 0.08
• 36 and over	0.99(0.90:1.30)	1.01 ± 0.10		1(0.87:1.20)	0.99 ± 0.09

p < 0.05 significance level

FD Fractal Dimension, SD Standard Deviation, a Mann-Whitney U test, b Kruskal Wallis H test,PM Premolar, M Molar

It was determined that there was a statistically significant difference between NS and OH in terms of FD in positions (p = 0.007). The median value of the difference was 0.01 in molar teeth and 0.05 in premolar teeth. Higher median values were obtained in FD NS and OH in premolar teeth (Table 4).

Table 4.

Comparison of the differences of fractal dimension in overhanging side and fractal dimension in nonoverhanging side according to tooth position, quadrant

Variable	FD in NS-FD in OH	p value
	Median(Min.:Maks.)
Quadrant
• 1	0.01(−0.10:0.10)	0.080b
• 2	0.02(−0.10:0.10)
• 3	0.03(−0.07:0.12)
• 4	0.05(−0.07:0.19)
Location
• Molar	0.01(−0.10:0.12)	0.007*a
• Premolar	0.05(−0.05:0.19)

p < 0.05 significance level

a Mann-Whitney U test, b Kruskal Wallis H test, FD Fractal dimension, NS Nonoverhanging side, OH Overhanging side

Discussion

Overhanging restorations can lead to bacterial plaque accumulation, triggering periodontal inflammation and predisposing to bone loss. Therefore, early detection of possible alveolar bone changes is crucial for the prevention of tooth loss and periodontal disease. In this context, the study of the effects of overhanging restorations on bone can contribute to the protection of periodontal health and help to develop more biocompatible approaches in restorative applications.

A comprehensive clinical and radiographic evaluation is paramount for arriving at an accurate diagnosis of overhanging restorations. Previous studies show that bitewing radiographs are primarily used to detect overhanging restorations [20, 26, 27]. However, there are also DPRs-based studies evaluating the effects of overhanging restorations on bone [19, 28]. In this study, readily available DPRs obtained during routine clinical practice were utilized, and a retrospective analysis was conducted to circumvent the need for further radiation exposure. Conversely, the focus on the fractal analysis (FA) of digital periapical radiographs (DPRs) has emerged as a prevalent and frequently utilized technique, enabling the quantitative evaluation of the trabecular structure of bone [14, 29, 30].

The present study found that FDs were significantly lower in areas with overhanging restoration compared to healthy areas (p < 0.001). This finding suggests that overhanging restorations may have deleterious effects on the bone trabecular structure. It can be deduced that the null hypothesis, formally expressed as H₀, which postulates the absence of a statistically significant difference between FD in OH and FD in NS, is to be rejected (p < 0.001).

Previous researches have indicated that overhanging restorations may potentially impact bone loss and trabecular structure. Millar et al. [26] found that annual bone loss was significantly higher in areas with overhanging restoration (0.16 mm/year vs. 0.06 mm/year, p = 0.01). In a similar vein, Tarçın et al. [31] demonstrated that alveolar bone loss was significantly higher in approximal restorations with overhanging edges (71.3% vs. 49.1%, p < 0.05). In a manner consistent with the present study, Büyükgöze Dindar et al. [19] utilized an analogous intact surface of the same tooth as a control group and ascertained that the bone density beneath the overhanging restoration was significantly lower in comparison to the control areas (p < 0.05). Conversely, certain studies have indicated that overhanging restorations do not induce substantial alterations in bone trabecular structure. In their analysis of bitewing radiographs, Yasar et al. [20] found no significant difference in Feret diameter (FeD) (p = 0.179) or FD (p = 0.963) in regions with and without overhanging restoration. This observation indicates that the presence of overhanging restorations does not invariably result in a direct alteration in bone density or trabecular structure. To conclude, the methodological discrepancies between studies, the patient characteristics, and the imaging techniques can potentially generate disparate conclusions regarding the impact of overhanging restorations on bone. The findings of this study demonstrate that FD were significantly lower in areas with overhanging restorations (p < 0.001), suggesting the possible effects of these restorations on alveolar bone trabeculation. This supports the idea that edge congruence in restorative procedures may be a critical factor for bone health. From a clinical perspective, the early detection and correction of overhanging restorations have been shown to prolong the life of the restoration, as well as contribute to the preservation of periodontal health and maintenance of bone integrity. Such restorations have been demonstrated to increase plaque accumulation, leading to gingival inflammation and bone loss over time. Consequently, early intervention is imperative to mitigate the risk of periodontal disease and to preserve alveolar bone structure.

Consistent with the findings of preceding studies, our investigation revealed a greater prevalence of overhanging restorations in molars compared to premolars [19, 26]31– [33]. Millar et al. [26] reported that overhanging restorations were most common in maxillary molars, followed by mandibular molars, maxillary premolars and mandibular premolars. Büyükgöze Dindar et al. [19] reported that overhanging restorations are more common, especially in the posterior maxilla. In line with the literature, our study found that overhanging restorations were more common in the maxilla, in the 1 st and 2nd quadrants, than in the mandible. The fact that overhanging restorations are more common in the maxilla can be explained by a number of anatomical and clinical factors. The more complex root anatomy of the upper molars can make it difficult to place matrix bands in this region. In addition, the need for indirect vision, the more limited access to the maxilla compared to the lower jaw and the narrower working range can make restorative procedures more difficult to perform. These factors can be considered as factors that increase the formation of overhanging restorations in the maxilla. FD in OH and NS did not show a statistically significant difference according to sex, but was found to be higher in people aged 36 years and over. Similarly, a study of alveolar bone loss in teeth with overhanging restorations found no difference between the sexes. Although the mean age and age range were reported in the same study, the relationship with bone loss or overhanging restoration by age group was not reported [26]. Tarçın et al. [31] found that alveolar bone loss on the overhanging surface was lower in the 18–29 age group compared to other age groups, but increased in individuals aged 30 years and older and it was also found to be higher in men than in women. The observation of different findings according to sex and age may be due to several factors such as population differences in the studies, age distribution, history of systemic diseases, duration of restorations and periodontal status of the individuals. Future large-scale and controlled studies may allow a more comprehensive evaluation of the effects of overhanging restorations on bone structure in relation to gender and age variables.

There was no statistically significant difference in FD values between premolars and molars within either the OH or NS groups (p > 0.05). However, when comparing FD values between NS and OH, a statistically significant difference was found (p = 0.007), with the discrepancy being more pronounced in premolars (0.05) than in molars (0.01). These results suggest that the effect of overhanging restorations on trabecular bone structure may vary depending on tooth type and location, with premolar regions potentially being more susceptible.

Previous studies support these observations. Although Yaşar et al. [20] included both premolars and molars, they did not evaluate FD differences between these tooth groups separately, instead focusing on the presence or absence of overhanging restorations. In another study, Yaşar and Akgünlü [22] reported that occlusal force differences between dentate and edentulous regions influenced trabecular bone patterns, with lower FD values observed in areas with active occlusal loading. Similarly, Temur et al. [30] found significant differences among FD values in various mandibular ROIs, with the highest values in the ramus region and the lowest in edentulous areas, further supporting the influence of anatomical site and dental status on bone microarchitecture.

Taken together, these findings emphasize that FD measurements are sensitive to regional factors, including the presence or absence of teeth, occlusal forces, and anatomical variation. For example, edentulous regions lacking mechanical stimulation typically exhibit reduced bone integrity and lower FD values. In contrast, dentate areas—particularly in the posterior mandible—may maintain more robust trabecular structures. Therefore, accurate interpretation of FD should account for tooth position, masticatory function, and local anatomical context to ensure meaningful radiographic assessment.

Our study’s strength lies in evaluating the effects of easily accessible DPRs, which are widely used in routine clinical practice, on the bone of protruding restorations. In addition, the retrospective design allowed evaluation without additional radiation exposure to patients. In addition, the high levels of intra-observer agreement increased the reliability of the measurements and supported the consistency of the study results.

Our study has some limitations. First, due to the retrospective design, gaps in patient records may affect the results of the study. The lack of clinical evaluation was a limitation in determining the direct effects of overhanging restoration on periodontal health. In addition, the study did not differentiate between types of restoration, and the effects of different materials and restorative techniques on bone could not be evaluated separately. In addition, the limitations of our study include not knowing when the overhanging restoration was performed and not being able to examine the condition of the bone before the overhanging restoration. These factors may limit the generalisability of the findings to restorative approaches.

Future studies should be prospective and include a combination of clinical and radiographic assessments to more fully evaluate the effects of overhanging restoration on alveolar bone tissue. In addition, studies comparing different restorative materials and techniques (direct and indirect restorations) may contribute to a better understanding of the effects on alveolar bone.

In addition, FD measurements should be taken at different time intervals (e.g. 6 months, 1 year, 3 years) to monitor the process of bone change and to evaluate the long-term effects of overhanging restoration. Occlusion analysis should be used to investigate the effect of overhanging restoration on load distribution and the relationship with bone loss.

In addition, the use of advanced imaging techniques, such as, CBCT can provide a three-dimensional assessment of bone loss, allowing more detailed analysis. In addition, long-term follow-up studies may help to develop more biocompatible and sustainable approaches to restorative dentistry by evaluating the effects of overhanging restoration on alveolar bone over time.

Conclusion

Despite the study’s limitations, its findings show that overhanging restorations may adversely affect the alveolar bone structure. These results demonstrate the importance of precise and careful restoration edge harmonization during restorative procedures. In this context, the early detection and correction of overhanging restorations may be an important clinical strategy for preventing changes in bone structure. FA appears to be a method that can evaluate the potential effects of flaccid restorations on bone; however, extensive and future studies are needed to better understand its clinical applicability.

Abbreviations

CBCT

Cone Beam Computed Tomography

DPR

Digital Panoramic Radiograph

FA

Fractal Analysis

FD

Fractal Dimension

TIFF

Tagged Image File Format

DRM

Digital Rights Management

OH

Overhanging side

NS

Nonoverhanging side

ROI

Region of interest

ICC

Intraclass correlation coefficient

Authors’ contributions

Conceptualization: S.K.K and K.T.T. Methodology: S.K.K and K.T.T. Investigation: S.K.K. Resources: M.G.B Formal analysis: S.K.K and K.T.T. Writing-original draft: S.K.K. Writing-review and editing: S.K.K and K.T.T. Visualization: S.K.K and K.T.T. Project administration: S.K.K and K.T.T.

Funding

The authors declare that no funds was received during the preparation of this manuscript.

Data availability

The data that support the findings of this study are available from the corresponding author on reasonable request.

Declaration

Ethics approval and consent to participate

The present study was approved by the Niğde Ömer Halisdemir University Non-Interventional Clinical Research Ethics Committee (Ethics Approval No: 2023/42). The research is being conducted in accordance with the ethical principles set out in the Declaration of Helsinki. Given the retrospective nature of our study, the ethics committee deemed the informed consent form to be exempt.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.