nestor cohenca clinical applications of cone beam computed … · 2015. 7. 21. · clinical...

VOLUME 46 • NUMBER 8 • SEPTEMBER 2015 657

Q U I N T E S S E N C E I N T E R N AT I O N A L

Clinical applications of cone beam computed tomography in endodontics: A comprehensive reviewPart 2: Applications associated with advanced endodontic problems and complications

Nestor Cohenca, DDS1/Hagay Shemesh, DMD, PhD2

The use of cone beam computed tomography (CBCT) in end-odontics has been extensively reported in the literature. Compared with the traditional spiral computed tomography, limited field of view (FOV) CBCT results in a fraction of the effective absorbed dose of radiation. The purpose of this man-uscript is to review the application and advantages associated

with advanced endodontic problems and complications, while reducing radiation exposure during complex endodontic pro-cedures. The benefits of the added diagnostic information provided by intraoperative CBCT images in select cases justify the risk associated with the limited level of radiation exposure. (Quintessence Int 2015;46:657–668; doi: 10.3290/j.qi.a34396)

Key words: cone beam computed tomography, dental trauma, intraoperative, outcome, root resorption

ENDODONTICS

have shown CBCT to be more accurate than conven-

tional periapical (PA) radiographs in measurement of

the length of root fillings12 and diagnosing the pres-

ence of resorption lesions,13-15 PA bone defects,16-20 root

fractures,21-23 and perforations.24 These studies under-

score the potential benefits of CBCT in diagnosis and

treatment of endodontic problems.

According to a web-based survey of active mem-

bers of the American Association of Endodontists (AAE)

in the USA and Canada, 34.2% of 3,844 respondents

indicated that they were utilizing CBCT. The most fre-

quent use of CBCT among the respondents was for

diagnosis of pathosis, preparation for endodontic treat-

ment or endodontic surgery, and for assistance in the

diagnosis of trauma-related injuries.25 CBCT should be

prescribed only after weighing the cost of radiation

exposure with the benefit of the diagnostic information

that can be obtained from the scan. In certain circum-

stances, however, use of limited field of view (FOV)

Since the first cone beam volumetric tomography

(CBVT) unit was approved for dental use in the United

States in 2000,1 numerous endodontic applications of

this technology, along with cone beam computed

tomography (CBCT), have been described in the litera-

ture. Most of these applications are focused on preop-

erative assessment and treatment planning, including:

diagnosis and canal morphology,2-4 assessment of inter-

nal2,4,5 and external root resorption,4,6,7 treatment plan-

ning and assessment of traumatic dental injuries,7,8

assessment of root fractures,2,9 presurgical anatomic

assessment,2,4 and treatment planning for tooth anom-

alies such as dens invaginatus.10,11 Comparison studies

1 Private Practice, Seattle, WA, USA; and Affiliate Professor, Department of Pediat-ric Dentistry, School of Dentistry, University of Washington, Seattle, WA, USA.

2 Associate Professor, Section for Endodontology, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands.

Correspondence: Dr Nestor Cohenca, 16633 NE 40th CT. Redmond, WA 98052-5245, USA. Email: [email protected]

Hagay ShemeshNestor Cohenca

VOLUME 46 • NUMBER 8 • SEPTEMBER 2015658


Cohenca/Shemesh

CBCT may actually reduce the number of plain PA

radiographs required during the course of endodontic

treatment. Recently, the AAE and the American Acad-

emy of Oral and Maxillofacial Radiology have jointly

developed a position statement regarding the use of

CBCT in endodontics.26 This joint statement clearly

delineated the indications and limitations of CBCT in

endodontics and concluded that limited FOV CBCT

systems can provide images of several teeth from

approximately the same radiation dose as two periapi-

cal radiographs, and they may provide a dose-saving

over multiple traditional images in complex cases.

The use of CBCT in dental traumatology was first

described in 2007.7,8 Cases that may appear straightfor-

ward on PA radiographs (Fig 1) might present a differ-

ent and more complex situation when evaluated

three-dimensionally. The radiographic examination

should include radiographs of the teeth in the injured

area. An occlusal radiograph and two PA radiographs,

mesial and distal, were recommended in an effort to

enhance diagnostics. However, due to the limitation of

plain, two-dimensional (2D) radiographs, current proto-

cols recommend utilizing three-dimensional (3D) imag-

ing such as CBCT, if available.

The diagnosis and 3D imaging assessment of the

resorption is important in order to determine the treat-

ment complexity and expected outcome based on the

location and extension of the root defect. In addition,

the proximity to anatomical structures is visualized for

a surgical approach. Several studies27-29 have reported

the geometric accuracy of CBCT, particularly regarding

linear measurements.

The intraoperative use of CBCT was first recom-

mended for location of calcified canals, evaluation of

unexpected anatomic findings, evaluation of missed

canals in endodontic retreatment, evaluation of root

resorption and root fractures, and assessment of iatro-

genic errors, such as perforation, fractured instruments,

and extruded obturation materials.30 Judicious use of

intraoperative limited FOV CBCT images may prevent

the occurrence of iatrogenic mishaps and reduce

removal of healthy tooth structure when anatomy of the

tooth is not fully apparent on standard PA radiographs.

Recent studies have reported the use of CBCT for

evaluation of endodontic outcomes. CBCT scanning

revealed lower healed and healing rates for primary

root canal treatment compared with PA radiographs

when the outcome was assessed after a 1-year fol-

low-up, particularly in molar roots.31 Kaya et al32 con-

ducted a clinical study to examine changes in bone

density in PA lesions before and after endodontic treat-

ment by using CBCT. Outcomes were evaluated at 2

years. The study supported the use of CBCT to measure

bone density before and after endodontic treatment.

The purpose of the present manuscript is to review

the application and advantages associated with

Figs 1a to 1d A 15-year-old patient presents to the emergency department, immediately after a traumatic injury. (a and b) Three maxillary incisors were clinically and radiographically diagnosed with complicated crown fractures with pulp exposure. Based on the clinical findings and two PA radiographs, the treatment plan developed included partial pulpotomies (vital pulp therapy). (c and d) A CBCT was taken to rule out any other injury. The presence of a crown-root fracture was further diagnosed on the maxillary right later-al incisor and the treatment plan was modified accordingly.

a b c d



Cohenca/Shemesh

advanced endodontic problems and complications,

while reducing radiation exposure during complex

endodontic procedures.

DENTAL-ALVEOLAR TRAUMAThe incidence of dental trauma as a result of falls, bicy-

cle accidents, skateboards, and other sports activities is

higher in children and adolescents, with maxillary inci-

sor teeth most commonly affected.33-35 Most maxillofa-

cial traumatic injuries involve the dentition alone (50%),

or both the dentition and adjacent soft tissue (36%).36

Maxillofacial fractures (13.6%) account for the remain-

ing types of injury.

The first clinical and radiographic examination of the

traumatized patient is crucial to determine the initial

diagnosis, severity of the injury, and treatment plan, and

to create a baseline for follow-up. However, traumatized

teeth present a clinical challenge with regard to their

diagnosis, treatment plan, and prognosis. Unfortunately,

film-based intraoral radiography provides poor sensitiv-

ity in the detection of minimal tooth displacements, and

root and alveolar fractures.37 This limitation is due to the

projection geometry, superimposition of anatomical

structures, and processing errors. CBCT has significantly

improved the ability to accurately diagnose traumatic

injuries, and has the potential to overcome most of the

technical limitations of plain film projection, with the

capability of providing a 3D representation of the max-

illofacial tissues in a cost- and dose-efficient manner.38

In 2007, Cohenca et al8 reported the use of CBCT for

diagnosis and treatment planning of traumatic injuries.

Often, even the mildest trauma might be more com-

plex than is apparent on the initial examination (Fig 1).

No current evidence-based literature is available to

correlate the use of CBCT and outcome of traumatic

injuries (level 5 of Fryback and Thornbury), thus the

need for scans should be judged individually according

to the severity of the injury.39

Alveolar and root fractureWith the advent of CBCT in recent years, a new tool is

available to accurately diagnose alveolar and root frac-

tures regarding their presence or absence, as well as

the exact location, extent, and direction of the fracture.

Limited FOV CBCT should be considered for diagnosis,

after considering the strengths and limitations of intra-

oral radiography. The usefulness of CBCT may be ques-

tioned in cases in which a single PA film has definitively

shown a fracture in the apical or coronal third of a root.

However, clinical outcomes depend on the exact loca-

tion of the fracture, extent of displacement, and poten-

tial connection of the fracture to the oral cavity.40 In

2004, Andreasen et al41,42 reported a significant correla-

tion between the healing pattern of root fractures with

diagnosis and treatment provided. Therefore, in a case

with an uncertain assessment from conventional radio-

graphs, CBCT should be considered. Recently, May et

al43 concluded that CBCT is most useful in cases in

which conventional radiography yields inconclusive

results or shows a fracture in the middle third of a root.

In such cases CBCT may rule out false negatives, ie, a

suspected root fracture not visualized with conven-

tional radiography. For a root fracture in the middle

third, CBCT may rule out or confirm an oblique course

of fracture involving the cervical third in the labio-lin-

gual dimension. When intraoral radiography shows a

fracture in the middle third or the absence of fracture in

a case when root fracture is suspected, CBCT is argu-

ably indicated. In the case of the former, CBCT is useful

because it can reveal the course of the fracture in the

sagittal plane. Current therapeutic guidelines pub-

lished by the International Association for Dental Trau-

matology (IADT) and the American Association of Endo-

dontists (AAE) recommended considering the use of

CBCT in cases with uncertain diagnosis (Fig 2).44-47

Injuries to the periodontiumPeriodontium injuries including lateral, extrusive, and

intrusive luxations, and avulsions can frequently lead to

concomitant injuries such as alveolar fracture. Taking

into consideration that the impact always comes in a

bucco-lingual direction, lateral luxations are character-

ized by the sudden displacement of the crown lingually

and the root bucally. Since the buccal cortical plate

covering central incisors is thin, lateral luxations are



Cohenca/Shemesh

commonly associated with alveolar fracture. Diagnosti-

cally, this can easily be missed on clinical and 2D radio-

graphic evaluation (Figs 3a and 3b), while clearly seen

on 3D imaging (Fig 3c). Accurate diagnosis leading to

the correct repositioning of traumatized teeth within

their alveolus will lead to more periodontal healing and

fewer complications.48,49

CBCT involves considerably more radiation com-

pared to PA radiographs and this difference is espe-

cially significant when scanning young children, who

represent the majority of patients suffering from dental

trauma. Although CBCT images could decrease the

number of PA radiographs taken from different direc-

tions to assess the location or severity of specific trau-

matic injuries, the ALARA (As Low As Reasonably

Achievable) principle should always be followed.

ROOT RESORPTIONCommon complications of dento-alveolar trauma are

pulp necrosis, pulp canal obliteration, PA pathosis, and

root resorption. The traumatic effect to the periodon-

tium depends on the type and severity of the injury and

can be related to different types of resorptions. These

have been identified as repair-related (surface), infec-

tion-related (inflammatory), ankylosis-related (osseous

Figs 2a to 2c Traumatic inju-ry to the maxillary incisors. (a and b) Periapical radiograph and clinical examination failed to provide a definitive diagno-sis on both central incisors. (c) The CBCT scan demonstrated the presence of root fractures on both teeth. (Courtesy of Dr Sebastian Ortolani, Spain.)

a b

c



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replacement), or extra-radicular invasive cervical

resorption.50,51 Eventually the resorptive process may

lead to tooth loss. Treatment of root resorption is often

complex, time consuming, expensive, and unpredict-

able. This is because plain 2D radiographs cannot

demonstrate the extent of the resorption and portals of

entry. In most cases the treatment requires a multidis-

ciplinary team of specialists that include the following

areas: endodontics, pediatric dentistry, periodontics,

oral surgery, implantology, prosthodontics, community

dentistry, and orthodontics.

The diagnosis and 3D imaging assessment of the

resorption is important in order to determine the treat-

ment complexity and prognosis based on the location

and extension of the root defect. In addition, the prox-

imity to anatomical structures is visualized for a surgical

approach. Lascala et al29 found that the measurements

made from the CBCT images are similar to those of real

in vivo distances between skull sites, and concluded

this is a reliable method for linear measurement

between anatomical sites. Additionally, CBCT offers the

advantage of a 3D visualization of the defect and facili-

tates determining the location, portal of entry/exit, and

the extension of the resorption (Fig 4). Better preoper-

ative assessment and understanding of the pathology

can help the operator to find and repair the affected

tissues (Fig 5). However, evidence-based literature con-

firming the added benefit of CBCT scans to the overall

success of treatment of resorptions is warranted.

INTRA- AND POSTOPERATIVE ASSESSMENTS OF ENDODONTIC TREATMENT COMPLICATIONSIn 2011, the AAE and the American Academy of Oral

and Maxillofacial Radiology (AAOMR) issued a joint pos-

ition statement regarding the use of CBCT in endodon-

tics.26 One indication cited in the joint position state-

ment of the AAE and AAOMR for the use of CBCT in

endodontics was “intra- or postoperative assessment of

endodontic treatment complications, such as overex-

tended root canal obturation material, separated end-

odontic instruments, calcified canal identification, and

localization of perforations”.26 Such intraoperative use

of CBCT aids in assessment of iatrogenic mishaps,

which greatly influence the outcome of endodontic

Figs 3a to 3d Lateral luxation of the maxillary left central incisor. (a and b) PA radiographs demonstrated what appears to be correct repositioning. (c and d) Further 3D imaging revealed a lateral luxation with fracture of the buccal cortical plate. (Courtesy of Dr Jose Maria Malfaz, Spain.)

Fig 4 Extracanal invasive root resorption (type III) on a maxillary central incisor.

c da b



Cohenca/Shemesh

treatment. The overall prognosis of endodontically

treated teeth has been shown to decrease due to per-

forations,52-55 presence of PA radiolucency,55-57 and over-

fill or underfill of obturation materials.58,59 Fracture

resistance of endodontically treated teeth has also

been shown to decrease when excessive tooth struc-

ture has been removed during endodontic treatment.60

Judicious use of intraoperative limited FOV CBCT

images may prevent the occurrence of iatrogenic mis-

haps and reduce removal of healthy tooth structure

when anatomy of the tooth is not fully apparent on

standard PA radiographs.

The use of intraoperative scans has been previously

reported, particularly in the head and neck but also in

vascular, spinal, thoracic, abdominal, and orthopedic

procedures.61-64 In 2013, Ball et al30 recommended the

use of limited FOV CBCT for cases with increased diffi-

culty or intraoperative complications. In essence, the

benefits of the added diagnostic information provided

by the intraoperative CBCT in select cases justify the

risk associated with the limited level of radiation expo-

sure. Ball et al29 recommended considering the use of

CBCT for:

• interpretation of root canal anatomy

• calcified canals

• establishing the clinical boundaries of therapy

• removal of separated instruments

• differential diagnosis of vertical root fractures

• management of root perforations.

When canals are identified but are subjected to calcifi-

cation, intraoperative CBCT has been shown to be a

powerful tool for assessing the extent of calcification,

thereby contributing to determining the proper

sequence of the treatment. 3D images allow for visual-

ization of the depth of calcifications and are critical to

Figs 5a to 5e (a) Extracanal invasive resorption (circle) on the maxillary left central incisor. (b) The CBCT helped in determining the precise location, portal of entry, and extension of the resorptive defect. (c and d) The information provided the critical information (circle) leading to the surgical repair. (e) One-year follow up.

a b c

d e



Cohenca/Shemesh

guide the clinician to the correct location, angle, and

depth to access the patent portion of the canal. Based

on an accurate measurement of the length and width

of canal walls and distance from important anatomical

structures provided by the CBCT, calcified canals can be

found and properly treated (Fig 6). On the other hand,

when complete calcifications were detected, the intra-

operative CBCT provided information to avoid the

unnecessary removal of tooth structure, particularly

when apical pathosis is not present and the risks of

attempting to expose a completely calcified canal are

unjustifiable (Fig 7).

Intraoperative scans should be considered only

after all other clinical means have been properly used.

The concept of using CBCT during therapy, when indi-

cated, will reduce unnecessary preoperative scans and

radiation, that otherwise would have been taken in

every challenging case.

ASSESSMENT OF ENDODONTIC OUTCOMES

The outcome of root canal treatments has been a sub-

ject of debate for many years.65 While tooth survival is

highly favorable,66 the complete healing of PA lesions is

very slow and usually takes years.67 Disappointingly, the

success rate of root canal treatments has not increased

over the years,65 suggesting that advances in technol-

ogy and materials have not influenced treatment out-

come significantly.

Healing of apical periodontitis Outcome was mainly determined on clinical signs and

symptoms and comparing pre- and posttreatment

radiographs for assessing the presence or healing of

the PA lesion. Since radiographs reveal only some PA

lesions, namely those that have penetrated through

Figs 6a to 6e (a) Maxillary second right premolar diagnosed with pulp necrosis and apical periodontitis. Following access through the existing crown, the root canals were not localized. (b to d) The tooth was temporarily sealed and an intraoperative CBCT taken. The presence of an apical lucency (circle) consistent with apical peri-odontitis was confirmed. (e) Accurate mea-surements were obtained and the calcified canals found and properly treated.

a b c

d e



Cohenca/Shemesh

the cortical bone,68 a significant number of lesions

could go unnoticed, even if radiographs are taken from

multiple angles.16 This puts in question the reliability of

assessing the outcome of root canal treatments with

radiographs. Wu et al69 claimed that assessing PA

lesions on radiographs can cause an overestimation of

favorable outcomes, while Pope et al70 claimed that

some healthy teeth demonstrate a widened periodon-

tal ligament space on CBCT, requiring a substantial

validation of CBCT as a tool for assessing healing of PA

lesions.

The PA Index (PAI) score is the prevailing method to

assess healing of PA lesions and outcome of root canal

treatments.71 The PAI score is based on a score from 1

(“normal PA structures”) to 5 (“demineralization of PA

bone with exacerbating features”). Scoring is based on

comparing a radiograph to a plate of five radiographs

from cadaver study.72 The comparison plate illustrates

PA regions of incisor teeth and was never validated for

other tooth types.69 Clearly, molar teeth present com-

pletely different surrounding anatomical structures and

bone thickness compared with the anterior region.68

Other disadvantages of the PAI score, such as inconsis-

tency in dichotomizing the score to healed and not

healed (PAI 1 or 2),73 and inaccuracy of the x-rays, led

researchers to develop the CBCT-PAI score,74 based on

a six-point score from 3D images in all planes. While

this score has the advantage that it is available for all

tooth types and specifies images from three planes, it is

still based on visually comparing images to a standard

plate.75

Outcome studies using CBCT are preliminary, lim-

ited to a small number of patients, and mostly have a

short follow-up period of 1 to 2 years. There are sub-

stantial variations in study design and criteria such as

sample selection, definition of success, duration after

Figs 7a to 7f (a) Maxillary second left molar presented for endodontic therapy. Upon access, three buccal canals were identified. However, the palatal canal was not found. (b to e) An intraoperative scan confirmed the presence of a very short and calcified palatal canal. (f) The root canal was successfully completed with no complications.

a b

c d e f



Cohenca/Shemesh

treatment, data collection and analysis, availability of a

preoperative CBCT scans, and type and quality of CBCT

scanner used. The first CBCT outcome studies to appear

did not have a preoperative CBCT scan, had a low recall

rate, and the quality of the treatments was question-

able.76 More recent CBCT outcome studies included

both pre- and postoperative CBCTs and the recall rate

was significantly improved.77-80 Some of these studies

even used 3D volumetric computations of PA lesions

(Fig 8).78,80 It is still too early to draw conclusions from

these preliminary studies; however, a few trends

appear to be consistent:

• Complete healing of the PA lesion rarely takes place

within the first 1 to 2 years after the treatment,

regardless of the size of the lesion; however, shrink-

age of the lesion is seen in more than 80% of

cases.80

• Interestingly, the emergence of PA lesions in teeth

that were vital at the time of treatment is a common

observation in all studies that included treatment of

vital teeth in 10% to 20% of cases.31,76

CBCT offers a more accurate way to assess the presence

and size of the PA lesion compared to radiographs.

However, difficult computation algorithms and

time-consuming procedures limit the information on

the outcome of root canal treatments to a number of

preliminary studies. Hopefully, more studies evaluating

larger populations for longer periods of time will

become available and will give an accurate insight into

predicting factors and outcome of root canal treat-

ments based on CBCT scans. Observations of the CBCT

appearance of healthy teeth will enable validation of

the method to differentiate between healthy and dis-

eased periodontal ligaments.

Systemically compromised patientsThe relationships between oral and systemic health are a

matter of controversy and much research. Recently,

attention has been focused on oral sepsis and its causal

relation to conditions such as cardiovascular diseases,

diabetes, respiratory disorders, osteoporosis, and adverse

pregnancy outcomes. Thus, the impact of oral infection

on systemic health has further defined the direction of

research in periodontology and endodontics.

Although a number of systemic medical conditions

were significantly associated with probing pocket

depth and/or clinical attachment loss,81 a clear causal

relationship between PA lesions and systemic health

was only established for a small number of patients

under certain conditions.82 However, most clinical trials

attempting to find a relationship had weak surrogate

parameters of risk, used different populations and age

groups, and control groups were often missing.

Fig 8 Measurements of PA lesions on a CBCT scan.



Cohenca/Shemesh

Clinical trials attempted to establish a causal rela-

tionship between PA health and cardiovascular disease

by way of radiographs and blood samples, checking

various markers related to cardiovascular disease. How-

ever, a concern was raised that radiographs are not

sensitive enough to detect PA lesions69 and thus are

not suitable for this purpose. Petersen et al83 used 3D

imaging to estimate the significance of apical peri-

odontitis for the atherosclerotic burden and to examine

the potential effect of endodontic treatment. The stat-

istical power was based on 531 patients and 11,191

teeth. Chronic apical periodontitis correlated positively

with the aortic atherosclerotic burden. In regression

models, chronic apical periodontitis without endodon-

tic treatment was found to be an important factor in its

correlation with atherosclerosis, while apical radiolu-

cencies in teeth with endodontic treatment were not.

DISCUSSION3D imaging is becoming an important and available

tool in dentistry. In selected cases, treatment planning

becomes easier and more accurate when using CBCT.

Better preoperative, intraoperative, and postoperative

imaging will lead to more accurate diagnosis and

development of a treatment plan. The incorporation of

CBCT has significantly improved the ability to accu-

rately diagnose traumatic injuries and root resorp-

tions.7,8,38

The estimated radiation risk is primarily influenced

by the age and gender, and includes the need for justi-

fication and optimization of CBCT exposures for chil-

dren.84 Thus, providers should be aware of the

increased radiation risk for children, and apply the

ALARA principle even more strictly compared to adult

patients.

Although 3D technology by itself will not directly

affect endodontic outcome, it might lead to better

diagnosis, prognosis assessment, and therapeutics,

with a potential for better outcome. The absence of

highly prospective randomized clinical trials underlines

the need for further research on the treatment out-

comes related to CBCT applications in endodontic ther-

apy. The cases illustrated in this paper emphasize the

need for treatment planning based on a comprehen-

sive evaluation using all diagnostic modalities avail-

able, including new 3D digital imaging techniques.

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