Endodontic Applications of 

CBCT
22
Scott L. Doyle, Bruno Azevedo, Martin D. Levin,
David Gane, Allan G. Farman, and William C. Scarfe

22.3.3.5  T  raumatic Injury  889

Contents 22.3.3.6  Root Resorption  891
22.1   Introduction  872 22.3.3.7  Periapical Non-dental Associated
Conditions  893
22.2   Imaging in Endodontics  872 22.3.3.8  Tooth-Associated Pathology (Not
22.2.1   imitations of Radiographic
L Necessarily Odontogenic in Origin)  899
Intraoral Imaging  872 22.3.3.9  Maxillary Sinus Disease  899
22.2.2  Advantages of CBCT in Endodontics  873 22.3.4  Intraoperative Applications  904
22.2.3  Challenges of CBCT for Use in 22.3.5  Postoperative Evaluation  907
Endodontics  875 22.3.5.1  Outcome Assessment for Select Cases  907
22.2.3.1  Technical  875 22.3.5.2  Complications Associated with
22.2.3.2  Interpretation  876 Endodontically Treated Teeth  909
22.3   Specific Applications  877 22.3.5.3  E ndodontic Retreatment Options:
22.3.1  Clinical Use Guidelines  877 Nonsurgical and Surgical  913
22.3.2   linical Efficacy: Effect on Diagnosis
C 22.3.5.4  Dental Implant Therapy  913
and Treatment Planning  878 Conclusion  913
22.3.3  Preoperative Assessment  878
22.3.3.1  Tooth Root Anatomy  879 References  914
22.3.3.2  Developmental Anomalies  883
22.3.3.3  Dental Periapical Pathosis  885
22.3.3.4  Early Radiographic Changes  886
M.D. Levin, D.M.D.
Department of Endodontics, School of Dental Medicine,
Univeristy of Pennsylvania, Philadelphia, PA, USA
S.L. Doyle, D.D.S., M.S. (*) e-mail: mlevin@dental.upenn.edu
Metropolitan Endodontics, Eden Prairie, MN, USA D. Gane, B.Sc. (hons), D.D.S.
Metropolitan Endodontics, Inver Grove Heights, MN, USA LED Medical Diagnostics, Inc., Vancouver, BC, Canada
e-mail: david.gane@leddental.com
Metropolitan Endodontics, Woodbury, MN, USA
Metropolitan Endodontics, Burnsville, MN, USA A.G. Farman, B.D.S., Ph.D., M.B.A., D.Sc.
Emeritus Professor, The University of Louisville
Division of Endodontics, Department of Restorative School of Dentistry, Louisville, KY, USA
Sciences, University of Minnesota School of
Dentistry, Minneapolis, MN, USA Independent consultant in Maxillofacial Imaging
e-mail: scottdoyle45@gmail.com Science, Chicago, IL, USA
e-mail: allanfarman@aol.com
B. Azevedo, D.D.S., M.S.
Division of Radiology and Imaging Science, W.C. Scarfe, B.D.S., F.R.A.C.D.S., M.S.
Department of Surgical/Hospital Dentistry, Division of Radiology and Imaging Science,
University of Louisville School of Dentistry, Department of Surgical/Hospital Dentistry,
Louisville, KY, USA University of Louisville School of Dentistry,
e-mail: bruno.deazevedo@louisville.edu Louisville, KY, USA
e-mail: william.scarfe@louisville.edu

© Springer International Publishing AG 2018 871

W.C. Scarfe, C. Angelopoulos (eds.), Maxillofacial Cone Beam Computed Tomography,
https://doi.org/10.1007/978-3-319-62061-9_22
872
22.1 Introduction
Endodontics is the specialty of dentistry concerned
with the morphology, physiology, and pathology
of the human dental pulp and periradicular tis-
sues. Its study and practice encompasses the basic
and clinical sciences including the biology of the
normal pulp and the etiology, diagnosis, preven-
tion, and treatment of diseases and injuries of
the pulp and associated periradicular conditions
(American Association of Endodontists 2012).
22.2 Imaging in Endodontics
Endodontics is an image-guided specialty, rely-
ing on radiographic assessments for diagnosis,
treatment planning, management, and follow-up
assessment of pulpal and periradicular disease.
Conventional radiography has historically been
the principle imaging modality used throughout
the stages of clinical endodontics (Walton 2008;
Basrani 2012):
1. Preoperative Assessment. According to a joint
statement by the American Association of
Endodontists (AAE) and American Academy
of Oral and Maxillofacial Radiology
(AAOMR) (AAE/AAOMR 2015):
Intraoral radiographs should be considered the
imaging modality of choice in the evaluation of the
endodontic patient.
Intraoral images serve as an indispensable
adjunct to endodontic examination (Gröndahl
and Huumonen 2004), providing visualization
of dental morphology such as information on
the location and number of canals, pulp chamber
size and degree of calcification, root structure,
length, and curvature. In addition, the effects of
pulpal and periradicular disease can be deter-
mined, including the degree of root resorption
and characteristics of periradicular osteolysis.
2. Intraoperative Assessment. Working images
with a rubber dam in place are used during
treatment to assess canal location, curvature,
and length. Although electronic apex loca-
tors are very accurate in determining working
length (Martins et al. 2014), the adjunctive
use of intraoperative radiographs is generally
recommended. Working length images with
S.L. Doyle et al.
files or master cones in place can help verify
that the canal is prepared and obturated to the
desired apical extent. Though controversial,
it is commonly accepted that instrumentation
and obturation should be terminated at the
apical terminus (Ng et al. 2008).
3. Postoperative Management. A post-­obturation
intraoral image is acquired to assess the length,
density, and taper of the root canal obturant.
This image is also used as a baseline for clini-
cal outcome analysis. Periodic checkup exam-
inations should be performed to monitor the
status of the apical tissues. The peak incidence
of healing or emerging apical periodontitis is
seen 1 year after treatment but complete heal-
ing may require as long as 4 years (Orstavik
1996). Most orthograde treated cases show
radiographic signs of healing within 1 year of
treatment, although some cases may require
longer follow-up intervals (Huumonen and
Orstavik 2002). Imaging is also important
when considering nonsurgical or surgical man-
agement of teeth with posttreatment disease.
22.2.1 Limitations of Radiographic
Intraoral Imaging
Conventional two-dimensional (2D) radiographic
imaging provides limited information in endodon-
tics due to variation in exposure (e.g., density and
contrast), geometric distortion (Gröndahl and Huu-
monen 2004), superimposition of structures, and
misrepresentation, particularly when the anatomy
of the teeth and surrounding tissues is complex.
The limitations of planar imaging can contrib-
ute to shortcomings related to diagnosis, access
preparation, cleaning and shaping, obturation and
post-space preparation. Intraoral imaging has limi-
tations in each of the following clinical situations:
• Visualization of Root Canal Anatomy. Tooth
morphology in the permanent dentition is
complex. Teeth show a wide range of varia-
tion, such as the number of roots/canals,
configurations, curvature, and length (Vertucci
1984). Superimposition of anatomic structures
and image distortion can impair canal identi-
fication and possible associated pathoses. 2D
images limit visualization to the mesiodistal
22  Endodontic Applications of CBCT
plane, with buccolingual and buccopalatal
features often absent. Multiple periapical
images from slightly varying angles are often
exposed to assist in visualization (Brynolf
1970; Walton 1973; Martinez-Lozano et al.
1999; Gröndahl and Huumonen 2004).
• Detection of Periapical Pathosis. An apical
lesion often requires extensive decalcification
of the cortical plate to be detected radiographi-
cally on conventional 2D images (Bender and
Seltzer 1961a, b; Bender 1982), with cancel-
lous lesions being more difficult to detect
(Schwartz and Foster 1971; Folk et al. 2005)
and often underestimated in size (Shoha et al.
1974; Lee and Messer 1986; Barbat and Messer
1998; Scarfe et al. 1999; Marmary et al. 1999).
• Assessment of Periradicular Tissue Healing.
Periapical radiography has historically been
used to monitor changes in the periradicular tis-
sues in order to assess outcomes following end-
odontic treatment. Favorable outcomes depend
on healing of the supporting bone. Repair of
periradicular tissues consists of a complex
regeneration involving bone, periodontal liga-
ment, and cementum (Huumonen and Orstavik
2002). Accurate determination of the true status
of periapical tissues is limited with conventional
radiography (Peters and Peters 2012). Healing
of periradicular lesions is assessed by interpre-
tation of periodic checkup radiographs but there
is a great degree of variability within and among
a b
Fig. 22.1  The periapical image of the maxillary right
second molar (a) in an asymptomatic patient is unremark-
able and shows lack of coverage of this tooth with marked
superimposition of the distal root of the first molar over
the mesial root of the second molar. The corresponding
873
observers when determining the outcome of
treatment (Goldman et al. 1972, 1974).
22.2.2 Advantages of CBCT
in Endodontics
CBCT imaging, especially limited field of view
(FOV), high resolution modalities, overcome
many of the limitations of conventional imag-
ing in contemporary endodontic practice by
producing undistorted and geometrically accu-
rate three-­dimensional images. This influences
how clinicians diagnose, treatment plan, manage
(Ee et al. 2014), and assess treatment outcomes
(Figs. 22.1, 22.2, 22.3, 22.4, and 22.5).
Specific advantages of CBCT for endodontics
include:
• Images are interactive and interrelational in
three orthogonal planes (axial, sagittal, and
coronal).
• The ability to reorient data such that coronal and
sagittal images are parallel with, and axial images
perpendicular, to the long axis of the root.
• Multi-planar reformation (MPR) images can be
used to highlight specific anatomic regions in
relation to endodontic investigation (Figs. 22.1
and 22.2).
• Enhancements including zoom or magnifica-
tion, window/level adjustments, and annota-
cropped sagittal thin section CBCT image (b) demon-
strates a furcal area of low density and associated perira-
dicular periodontitis. Subsequent clinical investigation
found the pulp in this tooth to be necrotic
874
a b
c d
Fig. 22.2  A periapical image (a) of the maxillary right
posterior region in a patient presenting with discomfort
extending from the nose to the ear, local buccal swelling
and induration. All teeth tested vital except the maxillary
right first molar. Periapical image (a) shows an area of low
density at the apices of the first and second molars. 10 mm
curved planar (b), axial (c), sagittal (d), and cross-­
sectional (e) CBCT images demonstrate a much larger
(21.4 mm maximum length) unilocular area of low den-
a b c
Fig. 22.3  Parasagittal (a), axial (b), and correlated mul-
tiple cross-sectional (c) images of a 52-year-old Caucasian
female presenting for assessment of multiple periapical
areas associated with the mandibular right first and second
molars. There are areas of mixed central opacity and
peripheral radiolucency associated with the apices of the
teeth however no expansion, tooth resorption or displace-
ment is evident. All teeth in this quadrant tested vital. A
S.L. Doyle et al.
e
sity centered on the palatal root of the maxillary first
molar, and extending to each tooth either side. Note the
internal resorptive defect at the junction of the apical and
middle thirds of the palatal root of the maxillary first
molar, not visible on the periapical image. Biopsy con-
firmed the lesion to be a periapical granuloma with
abscess formation at the time of root canal treatment and
surgery
digital panoramic image (d) revealed similar bony pat-
terns in the left posterior maxilla and mandible and con-
firmed the working diagnosis of florid cemento-osseous
dysplasia and concomitant hypercementosis on the right
mandibular first molar. Management of this patient com-
prised CBCT radiographic checkup at 6 months to assess
the progression of the hyperdensities
22  Endodontic Applications of CBCT 875

Fig. 22.3 (continued)

a b c

Fig. 22.4  Coronal CBCT image (a) showing moderately sectional (b) and axial (c) images demonstrate the palatal
sized periapical areas of low density associated with both extension associated with the maxillary left central inci-
endodontically treated maxillary central incisors. Cross-­ sor, important if surgery is to be performed

tion (text and arrows) can all be applied to the
images.
• Interactive, on-screen measurements provide
dimensions free from distortion and magnifi-
cation (Fig. 22.2).
• Assessment of a quadrant or sextant of teeth
and supporting bone in one image, which may
reduce radiation exposure compared to mul-
tiple intraoral images.
• Extraoral imaging in trauma cases where
placement of an intraoral detector would be
problematic.
• Quantification of volumetric data such as
amount of bony change and healing.
22.2.3 Challenges of CBCT for Use
in Endodontics
22.2.3.1 Technical
• Spatial resolution. The spatial resolution of
CBCT images (0.4–0.075 mm voxel size, equiv-
alent to 1.25–6.6 line pairs per mm−1(lp.mm−1))
is inferior to film-based (approx. 20 lp.mm−1) or
digital (ranging from 8–23 lp.mm−1) intraoral
radiography. The optimal resolution for CBCT
images in endodontics is task specific, invariably
involving imaging of inherently small structures.
Liedke et al. (2009) recommend a minimal
voxel resolution of 0.3 mm (1.6 lp.mm−1) for the
876
a b
Fig. 22.5  Thick section (10 mm) sagittal (a), thin section
sagittal (b), and axial image (c) showing a unilocular,
well-defined, tear-shaped relative hyperdensity associated
with the distal aspect of a left mandibular root canal
treated first molar. The patient was asymptomatic and
referred for an opinion with a concern for a possible
cementoblastoma, suggested by the loss of lamina dura
detection of external root resorption. Bauman
et al. (2011) investigated the effect of varying
isotropic voxel dimensions on the detection of
secondary canals in the mesiobuccal root of the
maxillary first permanent molar. They showed
that observer inter-rater reliability and detection
of mesiobuccal canals improves with increasing
resolution from 60.1% (0.4 mm/1.25 lp.mm−1)
to 93.3% (0.125 mm/4 lp.mm−1). The diagnosis
of subtler conditions (e.g., early stages of apical
periodontitis) involving the periodontal ligament
(PDL) space, which has an average dimension
of 0.2 mm, may demand resolution at or below
0.2 mm voxel size (2.5 lp.mm−1) (Scarfe et al.
2009).
• The presence of artifacts. CBCT images, like
those from other imaging modalities, are sus-
ceptible to artifacts that affect fidelity (see
Chap. 2). The presence of radiopaque metal
objects and root canal filling materials in the
field of view (FOV) can lead to severe beam
hardening and streaking artifacts. In clinical
endodontic practice, CBCT scanners with a
limited FOV may provide clearer images as
they can avoid scanning structures outside
S.L. Doyle et al.
c
and PDL space. No previous imaging was available, how-
ever the patient did report that endodontic therapy on this
tooth was performed approximately 2–3 years previously.
The homogeneous nature and confluence with adjacent
intramedullary bone is most consistent with sclerotic
healing
the region of interest susceptible to beam
hardening (e.g., metallic restorations, dental
implants). Cropping the FOV of the scan to
the root portion of the tooth may also negate
the effect of metallic artifacts. New algorithms
and flat-panel detectors promise to reduce
scatter and beam hardening artifacts in the
future (Dang et al. 2015).
• Contrast resolution. CBCT images also lack the
ability to record subtle changes in attenuation
of soft tissues. This feature would be of poten-
tial importance in distinguishing the nature of
periapical (e.g., abscess vs. cyst vs. granuloma)
or sinus soft tissue contents. Current CBCT
imaging is primarily limited to the assessment
of the dentition and osseous structures.
22.2.3.2 Interpretation
Interpretation of CBCT images requires consid-
erable experience and training. The clinician is
responsible for the evaluation of the entire image
volume, not only the tooth or pathosis in the
volume of interest. If a clinician has a concern
regarding image interpretation, the case should be
referred to an oral and maxillofacial radiologist.
22  Endodontic Applications of CBCT 877

22.3 Specific Applications case-­specific indications for CBCT use in end-

Numerous authors have published reviews illus-
trating the applications of CBCT imaging in end-
odontics (Cohenca et al. 2007a, b; Nair and Nair
2007; Cotton et al. 2007; Patel et al. 2007; Tyn-
dall and Rathore 2008; Scarfe et al. 2009; Patel
2009, 2010a; American Association of Endodon-
tists 2011; Tyndall and Kohltfarber 2012; Ball
et al. 2013; Venskutonis et al. 2014; Todd 2014a,
b; McClammy 2014; Mao and Neelakantan 2014;
Cohenca and Shemesh 2015; Patel et al. 2015;
Nair et al. 2015).
22.3.1 Clinical Use Guidelines
The American Association of Endodontists
(AAE) together with the American Academy of
Oral and Maxillofacial Radiology (AAOMR)
(AAE/AAOMR 2011; AAE/AAOMR 2015)
and The European Society of Endodontology
(ESE) (2014) have provided evidence-based,
odontics (Table 22.1).
In addition, both organizations provide spe-
cific parameters of care including:
• Justification. Patient exposure should be jus-
tified such that the total potential diagnostic
and therapeutic benefits are greater than the
individual detriment radiation exposure might
cause. CBCT should not be considered a
replacement for standard digital radiographic
applications. Rather, CBCT is a complemen-
tary modality for specific applications.
• Optimization. Practitioners follow profes-
sional judgment in minimizing the radiation
dose to the patient to that which is necessary
for diagnosis and treatment guidance.
–– FOV. Optimal FOV should be selected
based on disease presentation. Smaller
scan volumes generally produce higher res-
olution images and reduce radiation dose.
–– Spatial resolution. A discerning task in
endodontics is the detection and charac-

Table 22.1  Comparison of indications for Use of CBCT in Endodontics from The American Association of
Endodontists and American Academy of Oral and Maxillofacial Radiology (AAE/AAOMR 2015) and European
Society of Endodontology (2014)
Organization
Indication Example AAE/AAOMR ESE
Diagnosis of periapical pathosis when there Symptomatic teeth with no signs of ✓ ✓
are contradictory or nonspecific signs and/ pathosis, anatomic superimposition
or symptoms
Confirmation of nonodontogenic causes of Sinusitis of maxillary origin ✓ ✓
pathosis
Assessment and/or management of Severe luxation injuries, suspected alveolar ✓ ✓
complex dento-alveolar trauma fractures, horizontal root fractures
Appreciation of complex root canal Dens invaginatus, accessory canals, root ✓ ✓
systems prior to endodontic management curvature, root canal system anomalies
Retreatment—nonsurgical Untreated MB2, complex root canal ✓ ✓
anatomy
Assessment of endodontic treatment Post and root canal perforations, calcified ✓ ✓
complications canals, separated endodontic instruments
Assessment and/or management of root Internal or external resorption ✓ ✓
resorption
Assessment prior to complex periradicular Location of pathologic lesion, determine ✓ ✓
surgery optimal surgical access, locate vital
anatomical structures
Presurgical dental implant planning Immediate implant placement ✓
AAE/AAOMR The American Association of Endodontists and the American Academy of Oral and Maxillofacial
Radiology, ESE European Society of Endodontology, MB2 second canal of the mesiobuccal root of the maxillary first
molar
878
terization of disruptions in the PDL space,
small resorptive defects and localization
of calcified canals; an optimal resolu-
tion of approximately 0.125 μm or less is
preferred.
–– Exposure settings. The lowest mA setting
and the shortest exposure time in conjunc-
tion with a pulsed exposure mode of acqui-
sition are recommended.
–– Dose. Depending on the equipment used,
CBCT exposure may expose a patient to
comparable or slightly higher radiation
doses. This is especially important when
considering 3D imaging for children (up to
18 years old) and pregnant patients.
–– Task-specific imaging. Depending on the
diagnostic objective of the imaging study,
selecting a larger voxel size, 180° instead
of 360° rotation, or lower kVp and/or mA
can reduce radiation dose to the patient
(e.g., temporal imaging of the same area to
assess gross changes). Exposure parame-
ters can be reduced when acquiring a series
of radiographs to monitor bony changes
during checkup, as opposed to endodontic
assessments which generally require high
resolution, and hence increased exposure
parameters.
22.3.2 Clinical Efficacy: Effect on
Diagnosis and Treatment
Planning
The diagnostic efficacy hierarchical model is
used to appraise the efficacy levels for an imag-
ing modality (Fryback and Thornbury 1991).
The model presents six levels of imaging effi-
cacy: Level 1—Technical, Level 2—Diagnostic
accuracy, Level 3—Diagnostic thinking, Level
4—Therapeutic, Level 5—Patient outcome, and
Level 6—Societal efficacy. Systematic reviews
(European Commission SEDENTEXCT 2012;
Rosen et al. 2015; Kruse et al. 2015) on the diag-
nostic efficacy of CBCT imaging in endodon-
tics report that most studies have a low level of
efficacy (levels 1, 2, or 3), with none at level
6. However, recent Level 4 studies suggest that
S.L. Doyle et al.
preoperative CBCT imaging provides additional
diagnostic and treatment planning information
(Figs. 22.6 and 22.7).
Mota de Almeida et al. (2014a) compared
therapy plan changes before and after CBCT
imaging on 53 patients (81 teeth) referred from
specialty endodontic practices. The primary
reasons for referral were differentiating patho-
sis from normal anatomy (47%) and presurgi-
cal assessment (25%). Treatment plan changes
were made in 53% of patients after CBCT
imaging. In a related study using the same
database, the authors found that use of CBCT
imaging led to diagnostic changes in 41% of
patients and 35% of teeth (Mota de Almeida
et al. 2014b).
Ee et al. (2014) compared the relative diag-
nostic value of preoperative periapical images
alone to CBCT image findings on 30 patients in a
private practice setting. They used a preliminary
diagnosis and treatment plan based on clinical
diagnosis and the interpretation of both imag-
ing modalities as the diagnostic “gold” standard.
They found sensitivity to be 36.6–40% when
using periapical images alone and 76.6–83.3%
when CBCT imaging was used. The examiners
altered their treatment plan in 62.2% of the cases
after viewing the CBCT scan and concluded that
availability of a preoperative CBCT can directly
influence a clinician’s treatment plan.
It is important to emphasize that evaluation of
the patient’s chief complaint, history, clinical and
radiographic findings are all considered essential
to the formulation of a diagnosis and treatment
plan.
22.3.3 Preoperative Assessment
There are numerous situations in the assessment
phase of endodontics where CBCT imaging can
assist in the diagnosis and subsequent treatment
planning of endodontic disease and in the evalu-
ation of dental features that may affect therapy.
Teeth with anatomical variations and complex
morphology may be indications for 3D imaging.
CBCT is significantly better in terms of sensitiv-
ity, positive or negative predictive values, and
22  Endodontic Applications of CBCT
a b
c d
Fig. 22.6  Periapical image (a) of symptomatic maxillary
left first molar showing a periapical radiolucency suggest-
ing an untreated MB2 canal. Axial (b) CBCT image con-
firms the presence of an untreated MB2. Parasagittal (c)
and cross-sectional (d) CBCT images demonstrate an api-
cal area of low density, cortical bone resorption of the
diagnostic accuracy than digital or conventional
radiographs (Peters and Peters 2012) with the
exception of the assessment of vertical root frac-
tures of root-treated teeth (Talwar et al. 2016).
22.3.3.1 Tooth Root Anatomy
Anatomical variations exist with each tooth
and root type. The success of endodontic treat-
ment depends on the identification of all root
canal systems so that they can be accessed,
cleaned, shaped, and obturated (Vertucci 1984).
879
maxillary sinus floor, secondary soft tissue involvement
and a mid-root palatal resorptive defect. While nonsurgi-
cal retreatment may have been recommended based on the
periapical image, CBCT imaging substantially changes
the prognosis and treatment recommendation
A thorough understanding of specific root canal
anatomy is essential prior to initiating treatment.
Multiple in vitro (ex vivo) studies have vali-
dated the use of CBCT in identifying root canal
systems compared to multiple intraoral images
(Matherne et al. 2008; Neelakantan et al. 2010).
These studies report high detection rates com-
pared to histologic sections (Michetti et al. 2010)
and similar detection rates to staining and clear-
ing techniques on extracted teeth (Neelakantan
et al. 2010) (Fig. 22.8).
880
a b
c d
Fig. 22.7  Periapical image (a) of patient with vague pain
in the right mandibular area for several years with incon-
clusive clinical and microscopic findings. This image
Additional Canals and Roots
Maxillary molars have been frequently investi-
gated because of their complex root anatomy and
canal morphology. Many studies have reported
the presence of a second mesiobuccal canal
(MB2) in the mesiobuccal root of the maxil-
lary first and second molars (Weine et al. 1969;
Pineda and Kuttler 1972; Kulild and Peters 1990;
Fogel et al. 1994; Buhrley et al. 2002) and limita-
tions of intraoral radiography in identifying them
S.L. Doyle et al.
demonstrates extensive calcification of the unrestored first
molar. Axial (b), mesial (c), and distal (d) coronal CBCT
images show a significant mesial-distal fracture
(Pineda 1973; Nance et al. 2000; Ramamurthy
et al. 2006; Domark et al. 2013).
The frequency of MB2 is reported with vary-
ing methodology and results (Cleghorn et al.
2006). Contemporary instruments, enhanced
magnification, illumination, and experience are
critical to successful treatment. A clinical study
using the dental operating microscope reported
MB2 identification in more than 90% of maxillary
first molars and 60% of maxillary second molars
22  Endodontic Applications of CBCT
b c d e
Fig. 22.8  Cropped panoramic image (a) of a patient who
presented with pain/swelling in the mandibular anterior
region after multiple root canal treatments of the mandib-
ular teeth. Coronal CBCT images of the right canine (b),
(Stropko 1999). Clinicians should be aware that
untreated MB2 canals likely have a negative
impact on the outcome of endodontic treatment
(Wolcott et al. 2005; Huumonen et al. 2006).
Barato Filho et al. (2009) investigated the inter-
nal morphology of extracted maxillary first molars
using ex vivo sections, CBCT and clinical treatment
using an operating microscope. Results showed that
when an additional canal was present, it was located
in the MB root 92.85–95.63% of the time. Addi-
tional canals were also located in the DB and pala-
tal roots, though much less frequently. The authors
concluded that CBCT provides a good method for
the initial evaluation of maxillary first molar inter-
nal morphology. The location and identification of
the root canals were facilitated by the combined use
of an operating microscope and CBCT.
881
f
right (c) and left (d) central incisors, left lateral incisor (e)
and left canine (f) illustrate areas of low density with
asymmetry of the previous filling material and evidence of
untreated canal space
Blattner et al. (2010) assessed extracted max-
illary molars for the prevalence of MB2 canals.
They found an 80% correlation between the
results using CBCT and tooth sectioning. Viz-
zotto et al. (2013) showed CBCT to have higher
mean values of specificity and sensitivity when
compared to intraoral radiographs in the detec-
tion of the MB2 canal.
Bauman et al. (2011) investigated the effect of
increasing voxel resolution on the detection rate
of multiple observers of the MB2 on 24 maxillary
first molars by CBCT. Compared to the overall
prevalence of MB2 (92%), CBCT detection rates
increased from 60 to 93.3% with increasing reso-
lution, suggesting that if CBCT is to be used then
resolutions in the order of 0.12 mm or less are
optimal (Figs. 22.9 and 22.10).
882 S.L. Doyle et al.

a b c

SECOND MB CANAL

Fig. 22.9  A periapical image of a previously treated ciated with the mesiobuccal root. High resolution axial (b)
maxillary left first molar (a) with geometric distortion in and cross-sectional (c) CBCT imaging demonstrates an
the horizontal plane shows a periapical radiolucency asso- untreated MB2 canal

a b c

Fig. 22.10  A periapical image of a previously treated MB2 canal. Postoperative periapical image (c) shows
maxillary right first molar (a) shows a periapical radiolu- complete obturation of both mesiobuccal root canal
cency associated with the mesiobuccal root. High resolu- systems
tion axial (b) CBCT imaging demonstrates an untreated

a b c

Fig. 22.11  Periapical image (a) with corresponding parasagittal (b) and axial (c) CBCT images demonstrating right
maxillary first and second premolars with three distinct canal systems

All teeth types have the possibility for varia- 2014; Abella et al. 2015) (Fig. 22.11). An addi-
tions in roots and root canal anatomy (de Pablo tional disto-lingual root (radix entomolaris) with
et al. 2010; Silva et al. 2013; Llena et al. 2014; Paes significant curvature can be present in mandibular
da Silva Ramos Fernandes et al. 2014; Silva et al. molars (Tu et al. 2007, 2009; Abella et al. 2011).
22  Endodontic Applications of CBCT
CBCT scans may also be used as an adjunct
for determination of estimated working length
in select cases and have similar or greater accu-
racy to periapical radiographs for maxillary
posterior teeth (Metska et al. 2014) or elec-
tronic apex locators (Janner et al. 2011; Jeger
et al. 2012). If a preexisting scan is available,
length measurements can be used as an estimate
prior to treatment. Canal curvature may also
be assessed with CBCT images (Estrela et al.
2008a) and is particularly useful for detecting
curvature in the buccolingual or buccopalatal
plane.
The AAE/AAOMR (2015) state:
Limited FOV CBCT should be considered the
imaging modality of choice for initial treatment of
teeth with the potential for extra canals and sus-
pected complex morphology.
In addition to identifying canals, determining
the configurational relationship of multiple canals
within a root can also affect treatment decisions.
Accurate preoperative assessment may allow for
more conservative access and canal preparations,
reducing the possibility of iatrogenic errors dur-
ing preparation.
a b
Fig. 22.12  Right (a) and left (b) serial cross-sectional images of the lateral incisors with reformatted cropped pan-
oramic (c) and axial CBCT images showing Type II (a) and Type I (b) dens in dente on an asymptomatic female patient
883
22.3.3.2 Developmental Anomalies
Dental developmental anomalies are common
and many have endodontic significance (Ezod-
dini et al. 2007). CBCT imaging provides accu-
rate assessment of these conditions.
Dens Invaginatus (Dens in Dente)
Dens invaginatus is a malformation of indi-
vidual teeth that results from an invagination
of the dental papilla during development with a
reported frequency of 0.04–10% (Hovland and
Block 1977). It most commonly affects the max-
illary lateral incisors which accounts for 43% of
all cases (Grahnen et al. 1959) (Figs. 22.12 and
22.13), often bilaterally, but may occur in various
maxillary and mandibular teeth (Grahnhen et al.
1959; Hülsmann 1997; Hamasha and Alomari
2004) (Fig. 22.14). Dens invaginatus presents
with varying degrees of complexity and severity,
classified by Oehlers (1957) into three types:
• Type I: The minimal and enamel-lined invagi-
nation is confined to the crown of the tooth and
does not extend beyond the level of the external
cementoenamel junction (CEJ) (Fig. 22.12).
c
884 S.L. Doyle et al.

a b

d e

Fig. 22.13  The complexity of Type III dens invaginatus sagittal (e) CBCT images of this necrotic, asymptomatic
is demonstrated in by preoperative volumetric surface left lateral incisor
rendered (a), axial ((b), (c)), cross-sectional (d) and para-

a b c d

Fig. 22.14  Preoperative parasagittal (a), cross-sectional with pulp necrosis and symptomatic apical periodontitis.
(b), and axial (c) CBCT images showing the complexity Checkup image shows healing of the supporting bone fol-
of dens invaginatus in a mandibular right first premolar lowing orthograde root canal treatment
22  Endodontic Applications of CBCT
• Type II: The deeper and enamel-lined invagi-
nation extends below the CEJ but remains
within the root, ending in a blind sac. The pulp
shows no direct communication with the peri-
odontal ligament (Fig. 22.12).
• Type III: The severe invagination extends
through the root to form an additional apical
(IIIA) or lateral (IIIB) foramen (Fig. 22.13).
There is usually no direct communication with
the pulp. The invagination may be completely
lined by enamel but cementum may also be
present. In Type III variations, any infec-
tion within the invagination can lead to an
inflammatory response within the periodon-
tal tissues giving rise to a “peri-­invagination
periodontitis.”
A recent retrospective study using CBCT
found type I to be the most commonly observed
(65.9%), followed by type II (29.5%) and type III
(4.6%) (Capar et al. 2015).
Teeth affected by dens invaginatus are prone
to developing caries within the invagination that
may result in pulp necrosis and subsequent peri-
radicular periodontitis (Figs. 22.13 and 22.14).
Successful endodontic treatment depends on
characterization of the anatomical variations of
the anomaly including the irregular shape of the
root canal system and appreciation of the degree
of involvement of the pulp and/or invagination
(John 2008).
Taurodontism
The characteristic features of teeth with this con-
dition include an enlarged pulp chamber, apical
displacement of the pulpal floor and no constric-
tion at the level of the CEJ (Jafarzadeh et al.
2008). The prevalence of taurodontism has been
reported to range from 0.5 to 46.4% depending
on the population studied, with most authors
reporting from 5 to 10%. The trait has been
reported to be inherited as autosomal recessive
and associated with numerous syndromes and
conditions including cleft lip and palate (Laa-
tikainen and Ranta 1996), tricho-dento-­osseous
syndrome, Klinefelter’s, Williams, McCune-­
Albright syndromes, and probably most often
885
with Down syndrome. CBCT provides impor-
tant information characterizing this anomaly,
potentially important in endodontic treatment
considerations (Nawa et al. 2008; Borges et al.
2014).
Dilaceration
Dilaceration is a root anomaly with an abrupt
change in direction of the long axis of the root
of the tooth in relation to the crown. The defin-
ing criteria vary from a deviation of 20° in the
apical part of the root to a 90° or greater angle.
It can occur as a result of trauma, or occur spon-
taneously and has been associated with some
developmental syndromes. It can occur in both
deciduous and permanent teeth, more commonly
in posterior teeth and in the maxilla. The pres-
ence of a dilaceration can severely complicate
endodontic treatment (Jafarzadeh and Abbott
2007).
Gemination/Fusion
Both gemination and fusion are developmen-
tal disorders of individual teeth associated with
abnormalities in the differentiation of dental lam-
ina. Gemination occurs when two teeth develop
from one enamel organ producing a single root
structure with two partial or completely separated
crowns. Fusion is a union of two teeth, normally
with separated enamel organs leading to the for-
mation of a joined tooth with the confluence of
dentin. The clinician benefits from a knowledge
of the root canal system provided by CBCT for
treatment of both conditions.
22.3.3.3 Dental Periapical Pathosis
Apical periodontitis (AP) is generally considered
to be a sequelae of pulp necrosis and subsequent
microbial infection and results in local inflam-
mation, resorption of hard tissues, destruction of
other periapical tissues, and eventual formation
of various histopathological entities such as gran-
ulomas, cysts, or abscesses (Bhaskar 1968; Nair
2004). Because radiographic distinction between
these entities is difficult, the bony destruction
observed radiographically associated with AP is
commonly referred to as a periapical lesion.
886
a b
Fig. 22.15  Periapical image (a) of patient with pain in
the maxillary right quadrant, initially referred for retreat-
ment of the first molar. Parasagittal (b) and cross-sectional
22.3.3.4 Early Radiographic Changes
During the early stages of the inflammatory
process, there may be minimal or no periradicu-
lar radiographic changes (Barthel et al. 2004).
Periapical symptoms may or may not be pres-
ent. Eventually the periodontal ligament (PDL)
space, which appears as an approximately
200  μm-wide, low density feature surrounding
the root, becomes wider (thickened). PDL wid-
ening may progress to a more defined radiolu-
cency. PDL space widening due to AP must
be distinguished from other causes includ-
ing trauma from occlusion, orthodontic treat-
ment, tooth extrusion, root formation (dental
papilla), wide marrow space superimposed on a
tooth apex, or superimposition of a tooth apex
on radiolucent anatomical structures (such as a
nasal fossa, maxillary sinus, mental foramen, or
submandibular fossa).
Mature Radiographic Presentation
Most periapical lesions are asymptomatic, associ-
ated with teeth having necrotic pulps and appear
radiolucent on radiographs. Condensing osteitis
is the most common radiopaque lesion found in
the jaws and represents a localized bony reaction
to a low-grade inflammatory stimulus, usually
associated with root apices (American Associa-
tion of Endodontists 2012). Periapical lesions
of endodontic origin usually have the following
radiographic characteristics (Walton and Fouad
2015):
S.L. Doyle et al.
c
(c) CBCT images of the second molar indicate areas of
low density associated with all root apices and concomi-
tant sinus mucosal thickening
• Radiolucent
–– The lamina dura is absent apically.
–– The hypodensity remains at the apex of the
tooth and tends to resemble a hanging drop
(Fig. 22.15).
–– The cause of pulp necrosis is usually evi-
dent (e.g., dental caries, trauma, large
restoration).
• Radiopaque (Condensing osteitis or focal
sclerosing osteomyelitis)
–– Radiolucent apical epicenter associated
with the inflammatory lesion (Green et al.
2013).
–– Diffuse radiopaque border.
CBCT Detection
Ex vivo (Stavropoulos and Wenzel 2007; Ozen
et al. 2009; Soğur et al. 2009; Patel et al. 2009a)
and invivo (Lofthag-Hansen et al. 2007; Low
et al. 2008; Estrela et al. 2008b; de Paula-Silva
et al. 2009a, b; Patel et al. 2012a; Abella et al.
2014) studies indicate CBCT imaging (range;
61–100%) has an 18.8–54.2% higher AP detec-
tion rate than periapical radiography (range, 24.8–
44%), particularly for smaller lesions (Estrela
et al. 2008b; Abella et al. 2012) (Figs. 22.15 and
22.16). Periapical radiography frequently under-
estimates the size of the radiolucency compared
to CBCT (Tsai et al. 2012; Estrela et al. 2008b;
Christiansen et al. 2009).
Some authors suggest that true apical cysts
require surgical treatment, as they are less likely
22  Endodontic Applications of CBCT
a b
Fig. 22.16  Periapical radiograph of the maxillary left
second molar (a) shows an area of low density surround-
ing the mesial root with unfilled canal space. A parasagit-
tal CBCT image (b) shows a chronic periradicular
osteoperiostitis, or “halo lesion,” where the apical peri-
to resolve following nonsurgical root canal treat-
ment (Natkin et al. 1984; Nair 2003; Nair et al.
1993). Numerous investigators have suggested
that specific radiographic features can be used
to differentiate between cysts and granulomas.
These include:
• Cysts may be associated with a well-defined
hypodensity that may slowly enlarge and ulti-
mately cause expansion of the cortical plates.
• The peripheral border of radicular cysts may
be hyperostotic (sclerotic or corticated),
whereas the border of an apical abscess may
be diffuse and irregular.
However, differentiation between these enti-
ties based on these and other features on CBCT
imaging presentation have proven unreliable
(Simon et al. 2006; Rosenberg et al. 2010; Guo
et al. 2013). Surgical biopsy and histopathologi-
cal examination remains the current standard for
definitive diagnosis.
The AAE and AAOMR (2015) state:
Limited FOV CBCT should be considered the
imaging modality of choice for diagnosis in
patients who present with contradictory or nonspe-
cific clinical signs and symptoms associated with
untreated or previously endodontically treated
teeth.
When patients present with poorly localized
symptoms or suspected pathosis with limited
radiographic findings using conventional imag-
ing, CBCT may reveal the presence of previously
undetected disease. CBCT may also be indicated
887
c
odontitis has caused displacement of the periosteum but
does not penetrate the antral floor. Three months after
retreatment, CBCT imaging (c) demonstrates complete
apical resolution
to help confirm the absence of an odontogenic
etiology when managing nonodontogenic causes
of pain (Patel et al. 2015). Examples may include
patients with sinusitis or neuropathic pain-related
symptoms.
Residual (Persistent) Periapical Pathosis
Most apical lesions treated by nonsurgical root
canal therapy heal with hard tissue regenera-
tion, resulting in elimination or reduction of
the periapical radiolucency. However, in a pro-
portion of cases, asymptomatic radiolucencies
persist after root canal treatment. These may
be due to persistent intraradicular infection,
extraradicular infection (principally actino-
mycosis), extruded root canal filling or other
exogenous materials causing a foreign body
reaction, the accumulation of endogenous cho-
lesterol crystals that irritate the periapical tis-
sue, true cystic lesions, and scar tissue healing
of the lesion (Nair 2006). Radiographically, a
scar may appear as incomplete bone fill with
a radiopaque periphery and an internal radio-
lucency. Scar tissue is most commonly found
following apical surgery where there is a per-
foration of both the buccal and lingual or
palatal cortex. While most surgical sites heal
successfully within 12 months (Maddalone and
Gagliani 2003), some require longer periods
of time for complete resolution of the radiolu-
cency (von Arx et al. 2001; Testori et al. 1999).
CBCT may be considered for healing assess-
ment following apical surgery (Tanomaru-Filho
et al. 2015) (Figs. 22.17 and 22.18).
888
a b
Fig. 22.17 Cross-sectional (a) and parasagittal (b)
CBCT images of a patient with a large well-defined resid-
ual apical area of low density after root canal treatment of
the mandibular right central incisor. Cross-sectional (c)
a b
d e
Fig. 22.18  Initial intraoral periapical image (a) of a patient
presenting with localized right mandibular swelling and fis-
tula tract. The image shows a first premolar acting as a
bridge abutment with a large diffuse hypodensity (shown
with gutta percha). A periapical image of the tooth with
orthograde retreatment 6 weeks later (b). The patient pre-
sented 4 months later with similar signs and symptoms with
no apical resolution demonstrable on periapical images (c).
S.L. Doyle et al.
c d
and parasagittal (d) CBCT images 12 months after root
end resection and root end filling shows healing. The
biopsy revealed a periapical cyst. The adjacent teeth
remain responsive to vitality testing
c
f
CBCT volumetric (d), cross-sectional (e), and axial (f)
CBCT images taken at the time of the second presentation
show complete loss of buccal cortical plate and floating
hyperdense, presumably extruded material. In the absence
of a fracture, surgical curettage, apicoectomy, retrograde
endodontic treatment and guided tissue regeneration was
planned based on this second imaging presentation
22  Endodontic Applications of CBCT
22.3.3.5 Traumatic Injury
Numerous classification systems for describing
tooth injury have been proposed based on fac-
tors such as etiology, anatomic involvement of
the tooth, pathosis, prognosis, and therapy. These
range from basic (e.g., Ellis and Davey Classifi-
cation (Ellis and Davey 1970)) to comprehensive
(e.g., Sanders Classification (Sanders et al. 1979))
categorizations. The most widely used system,
adopted by the World Health Organization, is
the Andreasen classification system (Andreasen
and Andreasen 1994). This system divides dento-
alveolar injury into four major categories: dental
tissues and pulp, periodontal tissues, supporting
bone, and gingival and oral mucosa. Within the
dental hard tissue and pulp division, injuries are
classified as:
• Crown infraction. Incomplete fracture or
crack without loss of tooth structure.
• Uncomplicated crown fracture. Fracture con-
fined to enamel and/or involving dentin with-
out pulp exposure.
• Complicated crown fracture. Enamel and/or
dentin fracture with pulp involvement.
• Complicated crown-root fracture. Involves
enamel, dentin, and cementum with pulp
exposure.
a b
Fig. 22.19  Thin sectional cross-sectional (a) and sagittal (b) high-resolution CBCT images shows cervical horizontal
comminuted radiolucent lines and displacement of the palatal root fragments
889
• Root fracture. A fracture of the root involving
dentin, cementum, and pulp (Figs. 22.19 and
22.20).
Intraoral periapical imaging is often sufficient
to assess many of these conditions. CBCT imag-
ing is useful in the diagnosis of horizontal root
fracture and luxation injuries such as concussion,
subluxation, extrusive luxation, lateral luxation,
intrusive luxation, and avulsion (Bakland and
Andreasen 2004) (Fig. 22.21).
Root fractures due to trauma account for 0.5–
7% of dental impact injuries (Andreasen et al.
2007). Traumatically induced tooth fractures
are usually horizontal whereas those related to
previous root canal therapy or posts are vertical.
Horizontal root fractures (HRF) can be classi-
fied according to the location of the fracture line
(cervical, middle and apical thirds of the root).
HRFs in the middle third of the root are the most
common (Andreasen 1989) (Fig. 22.19) and
those located in the cervical third appear to have
the least favorable prognosis (Cvek et al. 2001,
2008).
Periapical radiography has limitations in
the assessment of HRFs (Cohenca et al. 2007a;
Palomo and Palomo 2009). The fracture line is
visible radiographically only if the X-ray beam
890
a b
Fig. 22.20 Periapical (a) and cross-sectional CBCT
image of an adolescent showing a middle third horizontal
root fracture of the left maxillary central incisor sustained
a b
Fig. 22.21  Periapical image (a) of an adolescent who
suffered from a traumatic blow to the anterior dentition. A
discontinuity of the interradicular bone between the max-
illary central incisors and slight widening of the PDL
space is noted. Thin cross-sectional (b), sagittal (c), and
axial (d) CBCT images show antero-medial lateral luxa-
passes directly through the fracture (Patel et al.
2015). Since root fractures often have an oblique
component in the sagittal plane (Andreasen
et al. 2007), multiple radiographs from vary-
ing angles are recommended to maximize the
likelihood of detection (Flores et al. 2007; Inter-
national Association of Dental Traumatology
2012).
Numerous authors have illustrated the use-
fulness of CBCT in the diagnosis (Figs. 22.16,
22.17, and 22.18) and management of dento-­
alveolar trauma, including root fractures (Tsuki-
boshi 2006; Cohenca et al. 2007a; Tyndall
S.L. Doyle et al.
c
due to a playground accident. The tooth was repositioned
and splinted with follow-up periapical image (c) showing
excellent approximation of the segments
c d
tion with displacement of the crown lingually and the root
facially. There is a concomitant alveolar fracture.
Compared to the findings of the periapical image (a),
CBCT provides more information regarding the tooth dis-
placement and associated alveolar fracture, which can
lead to better repositioning of the traumatized teeth
and Rathore 2008; Patel 2009; Bornstein et al.
2009; Iikubo et al. 2009; May et al. 2013).
Clinical outcomes depend on the exact loca-
tion of the fracture, extent of displacement, and
potential communication of the fracture to the
oral cavity.
The AAE and AAOMR (2015) state:
Limited FOV CBCT should be considered the
imaging modality of choice for diagnosis and
management of limited dento-alveolar trauma, root
fractures, luxation, and/or displacement of teeth
and localized alveolar fractures, in the absence of
other maxillofacial or soft tissue injury that may
require other advanced imaging modalities.
22  Endodontic Applications of CBCT
22.3.3.6 Root Resorption
Root resorption is defined by the American Asso-
ciation of Endodontists (2012) as:
A condition associated with either a physiologic
or pathologic process resulting in a loss of dentin,
cementum, and/or bone.
It may result from traumatic luxation injuries,
orthodontic tooth movement, or chronic infections
of the pulp and/or periodontal structures (Ne et al.
1999). Since root resorption is usually asymp-
tomatic, radiographic examination is critical to
determine the presence, extent, and location of the
defect. Based on the location in relation to the root
surface, root resorption can be classified as exter-
nal or internal (Gartner et al. 1976; Tronstad 1988).
CBCT is reported to be superior to periapical
radiography in the detection and localization of
external and internal resorptive defects (da Sil-
veira et al. 2007; Estrela et al. 2009; Patel et al.
2009c; Bernardes et al. 2012; Kamburoğlu et al.
2011; D’Addazio et al. 2011; Durack et al. 2011).
Others have presented selected cases illustrat-
ing the utility of CBCT in the detection of small
lesions, localizing and differentiating the resorp-
tion from other conditions, classification of the
lesion, determining prognosis and directing
treatment (Cotton et al. 2007; Patel and Dawood
2007; Maini et al. 2008; Cohenca et al. 2007b;
Patel et al. 2009c; Hahn et al. 2009). The accu-
racy of CBCT in the detection of surface defects,
while higher than conventional imaging modali-
ties, is not perfect (Hahn et al. 2009) and may
improve with increasing voxel resolution.
The AAE and AAOMR (2015) state:
Limited FOV CBCT is the imaging modality of
choice in the localization and differentiation of exter-
nal and internal resorptive defects and the determina-
tion of appropriate treatment and prognosis.
External Root Resorption (ERR)
ERR is a process that initiates in the periodon-
tium and affects the external surface of the root
(Andreasen 1985). Specific types include:
• Surface (repair-related). Transient process
involving small areas of the root surface fol-
lowing luxation and avulsion injuries. In the
absence of bacteria, the resorption is revers-
891
ible (Tronstad 1988). This generally has little
clinical significance.
• Inflammatory (infection-related). This is a
common complication following traumatic
luxation and avulsion injuries (Andreasen and
Vestergaard Pedersen 1985; Andreasen et al.
1995). Early detection is critical, as the pro-
cess can have a rapid onset and aggressive pro-
gression. External inflammatory resorption is
dependent on the presence of infected necrotic
pulp tissue within the root canal space; there-
fore, it is responsive to endodontic treatment
(Andreasen 1985). Radiographically, the
resorptive defect on the root surface has irreg-
ular borders and the surrounding bone may
have radiolucent areas.
• Replacement (ankylosis-related). Replacement
resorption (ankylosis) occurs as a complica-
tion following trauma to the PDL, especially
in luxation injuries such as avulsion. The root
surface is resorbed and replaced with bone.
Radiographically, the PDL space is absent and
has a characteristic “moth-eaten” appearance
(Tronstad 1988) (Figs. 22.22 and 22.23).
• External Cervical Resorption. External cervi-
cal resorption (Bakland and Andreasen 2004),
also referred to as invasive cervical resorption
(Heithersay 1999a), is a pathologic condition
occurring immediately below the epithelial
attachment of the tooth in the cervical region.
The pulp is not involved in the etiology and
often occurs in a tooth with a vital pulp (Patel
et al. 2009b). Predisposing factors include
a history of orthodontic treatment, dental
trauma, intracoronal bleaching, prior surgical
procedures, and periodontal therapy. Many
teeth have multiple associations. However,
cervical resorption is often idiopathic
(Heithersay 1999a, b, 2004). Clinical signs
are often absent in the early stages. However,
the appearance of a pinkish color in the tooth
crown is highly suggestive of late stage exter-
nal resorption as the highly vascular resorptive
tissue becomes visible through thin residual
tooth structure. External cervical resorption is
commonly misdiagnosed and confused with
caries and internal resorption on periapical
images (Fig. 22.24).
892
b c
Fig. 22.22  Reformatted panoramic (a), and serial cross-­
sectional (b) and coronal (c) CBCT images of a root-filled
maxillary right central incisor with a previous history of
a b
Fig. 22.23  Rendered volumetric image (a) of 14-year-­
old with a history of luxation of the deciduous maxillary
right central incisor and failure of eruption of the associ-
ated permanent central incisor. Sequential axial images
Heithersay (2004) reported a clinical classifi-
cation of invasive cervical root resorption based
on increasing severity (Table 22.2).
Internal Root Resorption (IRR)
IRR is an inflammatory process that initiates
within the pulp space and results in the loss of
internal tooth structure. Compared with ERR,
IRR is relatively rare (Haapasalo and Endal
S.L. Doyle et al.
trauma. The images show bone trabecular-like replace-
ment of the superior and palatal aspects of the apex con-
sistent with external replacement resorption
(b) show the irregularity of the mesial surface this tooth
and loss of PDL space suggestive of replacement resorp-
tion. Note concomitant external root resorption extending
to the pulp canal
2006). IRR has been associated with a history
of trauma, caries and periodontal infections,
pulpal inflammation and orthodontic treat-
ment (Haapasalo and Endal 2006; Caliskan
and Turkun 1997; Patel et al. 2010b). Accurate
assessment is essential as treatment regimens
may vary. Differentiating between IRR and ERR
may be challenging using periapical radiography
alone.
22  Endodontic Applications of CBCT
a b
Fig. 22.24  Unremarkable periapical image of the man-
dibular left anterior teeth (a) of a patient with history of
previous orthodontic revision for mandibular anterior
Table 22.2  Classification of invasive cervical resorption
(Heithersay 2004)
Classification Description
Class 1 Small, invasive resorptive lesion
characterized by shallow penetration
into the dentin near the cervical area
Class 2 Well-defined, invasive resorptive
lesion that has penetrated close to the
coronal pulp chamber but has little or
no extension into the radicular dentin
Class 3 Deeper invasion of the dentin that
involves the coronal dentin and
extends into the coronal third of the
root (Figs. 22.25 and 22.26)
Class 4 Large invasive resorptive process that
has extended beyond the coronal third
of the root
893
c
crowding. Right (b) and left (c) cross-sectional and axial
(d) CBCT images showing early (Class I) ERR on the left
and right canines
On CBCT, characterization of root resorption
is determined by location of the resorptive defect.
IRR usually appears as a round or oval-shaped
radiolucent “ballooning-out” of the root canal
and has smooth, well-defined regular margins
(Figs. 22.26, 22.27, 22.28, and 22.29).
22.3.3.7 Periapical Non-dental
Associated Conditions
Anatomic Features
Numerous anatomic landmarks of the jaws may
resemble periapical pathoses of dental origin,
most of which are low density. The most impor-
tant radiologic differential feature is whether the
894 S.L. Doyle et al.

a b

c d

Fig. 22.25  Periapical image (a) of an asymptomatic sectional (c), and axial (d) CBCT images demonstrate
patient referred for evaluation of possible internal resorp- Class 3 external cervical root resorption
tion of the left maxillary canine. Parasagittal (b), cross-­
22  Endodontic Applications of CBCT 895

Fig. 22.26  A series of cross-sectional images of the left maxillary canine (#11) showing a lesion of invasive cervical
external root resorption (solid arrow) combined with an internal resorptive site (dashed arrow)

a b c d

Fig. 22.27  Periapical image (a) of the right mandibular and cross-sectional (d) CBCT images show mid-root
first molar referred for retreatment showing periapical facial internal resorption
hypodensity on the distal root. Parasagittal (b), axial (c),

periodontal ligament (PDL) space is intact. Acute
dental inflammatory conditions eventually result
in widening of this space and are clinically asso-
ciated with pain, particularly on dental occlusion
or percussing the tooth. With chronic dentally
related periapical pathoses, pain may or may
not be a symptom; however, there is generally a
remodeling of the apical periodontal space with
an apical radiolucency having walls that merge
with the lamina dura. By way of comparison,
normal anatomic landmarks are superimposed
on the undisturbed PDL space. CBCT imaging
clearly identifies anatomical structures associ-
ated with the periapical regions including the
inferior alveolar canal, the mental foramen and
nutrient canals in the mandible, and the incisive
fossa and the maxillary sinus in the maxilla. The
incisive fossa may contain the foramina of Sten-
son and Scarpa, adding additional uncertainty
when these features are projected on the apices
of the maxillary central incisors using intraoral
periapical radiography.
896 S.L. Doyle et al.

a b

Fig. 22.28  Reformatted cropped panoramic (a) and cross-sectional (b) CBCT images of the left maxillary central inci-
sor showing internal resorption

a b

Fig. 22.29  Axial (a) and coronal (b) CBCT sectional images of the anterior maxilla showing a large internal resorptive
lesion (IRR) on the impacted right lateral incisor

Anomalies tical bone. It is self-limiting and consists of

There are numerous anomalies of the tooth-­
bearing areas of the jaws, most of which pres-
ent as a single separate hyperdensity, that may
be superimposed on the root system of the teeth.
CBCT can assist in the differentiation of these
conditions from pathologic entities.
• Exostosis. An exostosis is a hyperplastic,
localized, exophytic benign growth of cor-
either compact or spongy type bone. They
are important in endodontics as they may
simulate the appearance of intraosseous con-
ditions and complicate the provision of treat-
ment or limit surgical access. Three variants
exist:
–– Torus Palatinus. These are common single
exostoses that develop along the midsagittal
suture line of the posterior hard palate, and
22  Endodontic Applications of CBCT 897

a b c d

Fig. 22.30  Periapical intraoral image (a) and parasagittal
(b), cross-sectional (c) and axial (d) CBCT images of a
patient referred for evaluation due to discomfort in right
mandibular area. Clinic examination and vitality testing
were all normal with the exception of palpation tender-
ness on the lingual of molars. CBCT images demonstrate
an area of low density on the lingual aspect of the distal
root involving the lingual exostosis. Also note the buccal
exostosis. Biopsy confirmed necrotic bone consistent with
sequestra. The teeth have remained vital at the 2-year
checkup

while usually round, may be flat, spindle-­
shaped, nodular or lobular in shape.
–– Mandibular Torus. These occur on third as
frequently as torus palatinus and present as
bilateral exostoses on the lingual alveolar
crestal surface, adjacent the mandibular
premolars.
–– Alveolar Exostoses. Other less common
exostoses of the alveolar cortical plate
include palatal (palatal aspect of the maxil-
lary alveolus) or buccal (buccal alveolus of
either jaw) (Fig. 22.30) (Jainkittivong and
Langlais 2000; Horning et al. 2000).
• Enostosis. An enostosis is an intramedul-
lary growth of compact bone or a mixture of
compact and cancellous bone from the inner
aspect of the facial and lingual cortical plates, • Impacted tooth elements. Numerous entities in
often occurring in the mandibular canine and
premolar area inferior to the apices of teeth.
While radiographically indistinguishable from
osteosclerosis, it may simulate other more
aggressive conditions such as osteosarcoma.
• Idiopathic Osteosclerosis. This condition,
also called focal periapical osteopetrosis or
dense bone islands, is an infrequently occur-
ring (range, 4.1–6.7% (Geist and Katz 1990;
MacDonald-Jankowski 1999) localized intra-
medullary well-defined irregular hyperdensity
located in the mandibular molar and premolar
areas and usually associated with a tooth hav-
ing a vital pulp. They may present radiograph-
ically as (Yonetsu et al. 1997):
–– Enostosis (E type). This present as a local-
ized homogeneous thickening of either the
buccal or lingual cortical bone in a particu-
lar area.
–– Central sclerosis (CS type). This may pres-
ent as a solitary radiopacity in the medul-
lary bone without attachment to the internal
margin of the cortical bone. This type can
be further divided into homogeneous and
heterogeneous subtypes.
proximity to or superimposed on the roots of
the dentition include impacted and submerged
retained root fragments (deciduous or perma-
nent), microdontic teeth or developing teeth
(Fig. 22.31). Most present radiographically as
a homogeneous hyperdensity with the shape
of a tooth or root, a thin pericoronal or PDL
space, and a central linear hypodensity sug-
gestive of a root canal space.
898 S.L. Doyle et al.

a b

c d

Fig. 22.31  Periapical image (a) of root-filled left man- sectional (c), and coronal (d) CBCT images of the canine
dibular central incisor with apical radiolucency and buccal showing the loss of buccal cortical plate, lingual position-
cortical perforation involving a completely inverted and ing of the crown and association with the apex of the cen-
bony impacted canine. Volumetric rendering (b), cross-­ tral incisor
22  Endodontic Applications of CBCT
22.3.3.8 Tooth-Associated
Pathology (Not Necessarily
Odontogenic in Origin)
Various cysts and neoplasms can also be super-
imposed over the apices of teeth, and may result
in resorption of the lamina dura and tooth roots
(Table 22.3). CBCT can assist in differentiating
these conditions from inflammatory conditions.
In many instances the teeth concerned remain
vital to pulp testing. Several conditions are rela-
tively common, self-limiting, and require mini-
mal intervention; however, consideration should
always be given to those conditions that exhibit
aggressive growth patterns or have a high recur-
rence rate. Radiographically, these conditions
present as either radiolucencies (usually benign
but locally destructive), mixed and radiopaque
lesions (usually slow growing and benign) with
either uni- or multilocular borders (Table 22.3).
22.3.3.9 Maxillary Sinus Disease
A detailed description of specific diseases of
the maxillary sinus is presented in Chap. 29. As
the roots of the posterior maxillary teeth may be
intimately associated with the maxillary sinus,
radiographic differentiation between conditions
of intrinsic or extrinsic origin is important from
an endodontic perspective.
Intrinsic Sinus Disease
Incidental mucosal thickenings are common
imaging findings in asymptomatic individuals
Table 22.3  Examples of pathology associated with tooth apices, not necessarily odontogenic in origin.
Border Radiolucent
Unilocular • Nasopalatine canal duct cyst
• Lateral periodontal cyst (Botryoid • Focal cemento-osseous
odontogenic cyst)
• KOT (early) (Fig. 22.32)
• Central giant cell granuloma
(Fig. 22.33)
•  Aneurysmal bone cyst
•  Traumatic bone cavity
•  Focal COD (osteolytic)
Multilocular • Keratocystic odontogenic tumor •  Florid COD (mature)
• Ameloblastoma
• Central giant cell granuloma
• Odontogenic myxoma
KOT keratocystic odontogenic tumor, COD cemento-osseous dysplasia
899
(range, 14.3–82%) (Harar et al. 2007; Kanagal-
ingam et al. 2009; Vogiatzi et al. 2014). Radio-
graphic patterns on CBCT imaging include:
• Generalized polypoidal thickening. Regular or
irregular (polypoidal) soft tissue thickening (>
3 mm) with partial or complete coverage of
the periphery of the maxillary sinus.
• Localized polyps. Localized soft tissue mass
appearing as somewhat pedunculated polyps
with a smooth outline usually originating
from the roof or lateral walls of the maxillary
sinus (Vogiatzi et al. 2014) (Fig. 22.35)This
­imaging appearance is similar for three (3)
different entities: antral mucosal pseudocyst,
mucous retention cyst (which occur near the
ostium), and mucocele (complete opacifica-
tion associated with peripheral bony erosion).
• Rhinosinusitis. Rhinosinusitis presents as par-
tial or complete sinus soft tissue opacification
with surface air locules and peripheral con-
vexity (acute). It may also be associated with
peripheral sclerosis and osteoblastic osteitis
(linear calcifications adjacent the cortical
border), both of which suggest chronic rhino-
sinusitis. Allergic rhinosinusitis often has gen-
eralized bilateral and adjacent mucosal (nasal)
thickening.
• Fungal sinusitis, while uncommon, is of par-
ticular importance in endodontics. Based on
the radiographic pattern of bone involvement
and presence of central calcifications, fungal
Radiopaque Radiomixed
• Odontoma (compound • Focal COD (intermediate)
and complex) (Fig. 22.34)
• Cementoblastoma
dysplasia (mature)
• Osteoblastoma
• Osteosarcoma
•  Florid COD (mature)
900
a b
c d
Fig. 22.32  Periapical image (a) of patient referred for
evaluation of soft tissue swelling in the maxillary right
canine area. Pulp testing was normal. Volumetric render-
ing (b), axial (c), parasagittal (d), and cross-sectional (e)
CBCT images demonstrate a unilocular apical area of low
sinusitis can be classified into two types
(Aribandi et al. 2007):
• Noninvasive or allergic fungal sinusitis, usu-
ally presents with involvement of multiple
sinuses, mimicking pansinusitis and associ-
ated rhinitis, with near-complete opacifica-
tion. Peripheral bony expansion with erosion
is an important imaging feature.
S.L. Doyle et al.
e
density with buccal cortical perforation (radiographic sign
of aggression) with no change in PDL space.
Histopathology reveals a keratocystic odontogenic tumor.
Entities in this region, with various histopathology, had
previously been referred to as “globulomaxillary cyst”
• Fungus ballor fungal mycetoma is an extramu-
cosal fungal proliferation, mostly caused by
Aspergillus spp., often involving the maxil-
lary sinus (Pagella et al. 2007). Many patients
present with a history of facial pain or rhi-
norrhea and a history of previous endodon-
tic treatment. Aspergillosis of the maxillary
sinus has been reported in association with
22  Endodontic Applications of CBCT
a b
c d
Fig. 22.33  Premolar (a) and molar (b) periapical images
of an asymptomatic patient undergoing active orthodontic
therapy referred for evaluation of the mandibular right
quadrant. These images show a generalized area of rar-
efaction in the interradicular bone between the first molar
and second premolar but no changes in the lamina dura.
a b
Fig. 22.34  Periapical image (a) of asymptomatic middle-­
aged African-American female referred for evaluation of
mixed hyper- and hypodensity associated with the apices
of both mandibular right premolars. Parasagittal (b),
cross-sectional (c), and axial (d) images show associated
901
e
Pulp testing was within normal limits. Parasagittal (c),
axial (d), and cross-sectional (e) CBCT images show a
large, well-defined, non-corticated periapical area of low
density with buccal cortical expansion, furcation involve-
ment and thinning. Histopathology reported a central
giant cell granuloma
c d
buccal expansion without perforation of the cortical plate.
Together with the history, the imaging appearance is most
consistent with focal cemento-osseous dysplasia
(intermediate)
902
a b
Fig. 22.35  Parasagittal (a) and cross-sectional (b) CBCT
images showing typical homogeneous dome-shaped
appearance of an antral mucosal pseudocyst. Unlike peri-
apical mucositis, which is associated with a periapical
extrusion of root canal material with cer-
tain cements (Khongkhunthian and Reichart
2001; Giardino et al. 2006). There is almost
total opacification of the sinus, with sclero-
sis and thickening or expansion and thinning
with focal areas of erosion from pressure
necrosis occurring in approximately 1/3rd of
cases. The unique appearance of metallic or
highly calcified central, punctate, hyperdense
­calcifications within an opacified sinus cavity
is considered a characteristic finding.
Extrinsic Sinus Disease
Dental infection may often be a major predis-
posing factor in the development of maxillary
sinusitis. This may be due to an oroantral fistula,
secondary to periapical, periodontal or pericoronal
disease or associated with endodontic treatment
(Engström and Ericson 1964; Legert et al. 2004).
• Endo-Antral Syndrome (EAS) (Selden 1989,
1994, 1999). This results from the spread of
pulpal disease beyond the apex into the max-
illary sinus. CBCT clearly demonstrates the
features of EAS (Angelopoulos 2008; Patel
et al. 2007b; Shanbhag et al. 2013), which is
characterized by one or more of the following:
S.L. Doyle et al.
lesion, antral mucosal pseudocysts do not disrupt the floor
of the sinus nor expand superiorly from the apices of the
roots of adjacent teeth
–– Associated with a tooth having pulpal dis-
ease whose apices approximate the floor of
the maxillary sinus.
–– The presence of a periapical radiolu-
cency with the involved tooth (periapical
osteoperiostitis).
–– Radiographic loss of the lamina dura at the
inferior border of the maxillary sinus over
the involved tooth.
–– Periapical mucositis. Localized reactive,
relatively hyperdense soft tissue swelling
and thickening of the sinus mucosa above
the apex of a pulpally involved tooth. The
apical lesion may displace periosteum
resulting in a “halo” of thin peripheral
layer of new bone (Bornstein et al. 2012;
Vogiatzi et al. 2014) (Fig. 22.36).
–– Maxillary sinusitis of dental origin
(MSDO). MSDO (Bauer 1943) has been
reported to account for approximately
5–10% (Maloney and Doku 1968; Mehra
and Murad 2004; Vogiatzi et al. 2014) and
even more than 50% (Malliet et al. 2011;
Lu et al. 2012) of all cases of sinusitis and
presents as partial or complete opacifica-
tion of the lumen of the maxillary sinus
(Fig. 22.37).
22  Endodontic Applications of CBCT 903

a b

c d

Fig. 22.36  Periapical image (a) of a patient referred for apex. Axial (b), parasagittal (c), and cross-sectional (d)
endodontic evaluation of maxillary left first molar shows CBCT images show palatal apical periodontitis with large
loss of lamina dura of the palatal root and possible scle- cortical “halo” expanding superiorly into the lumen with
rotic apical radiolucency concentrically located over the concomitant periapical mucositis

Resolution of MSDO cannot occur until the mucosal thickening will occur after extraction
identified tooth is endodontically treated or or endodontic treatment. Mucosal thickening
extracted. Currently, there is a lack of evidence may persist for more than 3 months postopera-
to suggest that complete resolution of localized tively (Nurbakhsh et al. 2011; Yoo et al. 2011).
904 S.L. Doyle et al.

a b

c d

Fig. 22.37  Periapical image (a) of a patient with left
maxillary pain shows partial elevation of the floor of the
maxillary sinus and loss of lamina dura adjacent to the
apex of the mesiobuccal root of the endodontically treated
first molar. Axial (b), parasagittal (c), and cross-sectional
(d) CBCT images show a periapical hypodensity associ-
ated with an untreated MB2. The lack of cortical integrity
superior to the MB root and accompanying partial opaci-
fication with surface air locules is consistent with acute
MSDO

22.3.4 Intraoperative Applications calcified canals and by providing information

Limited FOV CBCT may be useful in dif-
ficult cases requiring surgical or nonsurgical
­endodontic treatment and those presenting with
intraoperative complications such as:
• Location of calcified canals. CBCT can assist
in determining the extent of obstruction of
on the location, angle, and depth to access the
patent portion (Fig. 22.38). CBCT may also
identify completely calcified canals that may
not be accessible to nonsurgical treatment.
Unnecessary removal of tooth structure, espe-
cially in the absence of apical pathosis, may
be avoided and the risk of perforation reduced
(Cohenca and Shemesh 2015).
22  Endodontic Applications of CBCT
a b
c d
Fig. 22.38  Intraoperative periapical image (a) of a max-
illary left central incisor with an instrument inserted into
the root canal after initial mechanical preparation through
a calcified obstruction in the mid third of the root. Axial
(b) and cross-sectional (c) CBCT images with gutta per-
cha placed in the palatal sinus tract shows involvement of
905
DRAINAGE
the incisive canal. A cross-sectional CBCT image (d) with
gutta percha inserted into the canal shows the mechanical
preparation was directed palatally. The access was redi-
rected facially, resulting in negotiation of the canal to the
apex
906 S.L. Doyle et al.

• Evaluation of unexpected anatomic findings.
• Identification of missed canals in endodontic
retreatment.
• Evaluation of root resorption and root
fractures.
• Assessment of possible iatrogenic errors such
as perforation, fractured instruments, and
extruded obturation materials (Figs. 22.39
and 22.40).
The benefits of the additional diagnostic infor-
mation provided by intraoperative CBCT in select
cases justify the risk associated with the limited
level of radiation exposure (Ball et al. 2013). The
AAE and AAOMR (2015) state:
If a preoperative CBCT has not been taken, limited
FOV CBCT should be considered as the imaging
modality of choice for intra-appointment identifi-
cation and localization of calcified canals.

a b c

Fig. 22.39  Coronal CBCT image (a) of patient referred sectional CBCT image (b) shows facial direction of initial
for completion of root canal treatment on maxillary right access, however no perforation. Periapical image (c)
lateral incisor showing area of low density. Cross-­ shows completed root canal treatment

a b c d

Fig. 22.40  Cropped periapical image (a) of a mandibular CBCT images used after placement of calcium hydroxide
right second molar with moderately sized low density api- to confirm containment within the canal. Periapical image
cal area in close approximation to the mandibular canal. (d) shows completed treatment with filling material con-
Intraoperative parasagittal (b) and cross-sectional (c) fined to the canal
22  Endodontic Applications of CBCT
22.3.5 Postoperative Evaluation
The assessment of outcome is important in
endodontics, especially in medically com-
plex patients, such as patients with prosthetic
heart valves, orthopedic prostheses, at risk of
medication-­ related osteonecrosis of the jaw
(MRONJ), or immunocompromised, to name
a few. A favorable outcome for root canal
­treatment is dependent on appropriate diagnosis,
effective instrumentation and disinfection, obtu-
ration of the root canal system, and subsequent
coronal seal and restoration. Outcome measures
have historically incorporated a strict combina-
tion of radiographic and clinical criteria to define
“success” and “failure” (Strindberg 1956). The
absence of clinical symptoms and apical lesions
is an indicator of successful root canal treatment.
Apical periodontitis is frequently asymptomatic
and can often only be detected radiographically
(Huumonen and Orstavik 2002).
The European Society of Endodontology
(2006) defines a favorable outcome as the absence
of pain, swelling, and other symptoms, no sinus
tract, no loss of function, and radiological evi-
dence of a normal periodontal ligament space
around the root. As an alternative to the concepts
implied by the terms “success” and “failure,” the
American Association of Endodontists (2012)
has proposed the following terms:
• Healed: Functional, asymptomatic teeth with
no or minimal radiographic periradicular
pathosis (radiolucency).
• Nonhealed: Nonfunctional, symptomatic teeth
with or without radiographic periradicular
pathosis.
• Healing: Teeth with periradicular pathosis,
which are asymptomatic and functional, or
teeth with or without radiographic periradicu-
lar pathosis which are symptomatic but whose
intended function is not altered.
• Functional: A treated tooth or root that is serv-
ing its intended purpose in the dentition.
Postoperative endodontic assessment should
include clinical examination and intraoral
periapical radiographic imaging immediately
907
posttreatment and until complete healing is
observed. The recommended timeframe for
checkup examinations varies but follow-ups
at regular intervals for a minimum observa-
tion period of one year is generally suggested
(Orstavik 1996; Reit 1987; European Society
of Endodontology 2006). Endodontic treatment
options for teeth with persistent signs and symp-
toms following initial treatment include ortho-
grade retreatment, endodontic microsurgery, and
removal of the tooth with or without replacement.
While conventional intraoral radiography
often provides adequate imaging for postop-
erative assessment, CBCT has a unique role in
monitoring lesion resolution for certain cases,
diagnosis and management of endodontic com-
plications, imaging prior to periradicular surgery
and for planning alternate treatments.
22.3.5.1 Outcome Assessment
for Select Cases
Monitoring the resolution of apical lesions is an
important aspect of postoperative assessment in
endodontics (Figs. 22.41 and 22.42). The AAE
and AAOMR (2015) indicate:
Intraoral radiographs should be considered the
imaging modality of choice for immediate postop-
erative imaging.
They are also used routinely to assess the out-
come of endodontic treatment. However, inter-
pretation of apical healing on periapical images
has limitations and a great degree of variability.
Preoperative factors such as the presence and
true size of periapical lesions play an impor-
tant role in determining endodontic treatment
outcome. It is generally accepted that preven-
tion of apical periodontitis is more predictable
than the treatment of apical periodontitis. Suc-
cess, when measured by radiographic criteria,
is higher when teeth are endodontically treated
before radiographic signs of periapical disease
are detected (Friedman 2002). Therefore, radio-
graphic identification of early periapical radio-
graphic changes may result in earlier diagnosis
and treatment and in faster or more complete
healing (Patel et al. 2007b, 2009a). On average,
apical lesions on periapical radiographs are at
908 S.L. Doyle et al.

a b

c d

Fig. 22.41  Periapical image (a) of patient who presented image confirms the extent and proximity of the lesion to
with dysesthesia associated in the right posterior mandible the mc. Postoperative parasagittal (c) CBCT image and
showing a large apical and interradicular rarefaction adja- digital subtraction composite image (d) at 6 months shows
cent to the mandibular canal (mc). Parasagittal (b) CBCT bony healing (blue)

least 10% smaller on CBCT (Tsai et al. 2012;
Estrela et al. 2008b; Christiansen et al. 2009;
Peters and Peters 2012).
Periapical images may therefore result in an
overestimation of favorable outcomes (Wu et al.
2009). The use of CBCT provides a more objec-
tive representation of dynamic osseous changes
over time (Pinsky et al. 2006; Patel et al. 2007b,
2015; Kaya et al. 2012). However, outcome
assessment may be complicated as some healthy
teeth demonstrate a widened PDL space on CBCT
(Pope et al. 2014). In addition, investigators have
shown that healed rate for CBCT is much lower
than for periapical images (Patel et al. 2012b).
Various indices and scales to assess outcomes
with CBCT have been proposed (Estrela et al.
2008c; Venskutonis et al. 2015) including api-
cal lesion area or volumetric analysis (Alhowalia
et al. 2013; Van der Borden et al. 2013; Metska
et al. 2013) which appear to provide reliable
results. Other factors affecting treatment out-
comes such as root canal length and radiodensity
(Ng et al. 2008) can also be determined. Liang
et al. (2011) found 80% of apparently short apical
22  Endodontic Applications of CBCT
a c
Fig. 22.42  Cross-sectional CBCT image (a) and surgical
photograph (b) of a symptomatic patient showing a large
periapical lesion associated with an endodontically treated
maxillary left central incisor. After apical microsurgery
treatments on intraoral radiographs correspond to
the apical terminus on CBCT images. In addition,
they found CBCT identified the presence of voids
in almost 3× as many teeth as periapical images.
CBCT will likely become more important for
assessing the dynamics of periapical disease;
however, currently studies are limited (Cohenca
and Shemesh 2015).
22.3.5.2 Complications Associated
with Endodontically Treated
Teeth
Vertical Root Fracture (VRF)
VRF is a longitudinal fracture of an endodonti-
cally treated tooth root that develops over time
due to predisposing and/or iatrogenic factors
(Tamse 2006; Kishen 2006). Associated variable
signs, symptoms, and radiographic findings can
make diagnosis difficult.
VRF usually initiate apically but may develop
at variable locations along the root and propa-
gate either apically or coronally. VRFs originate
from the root canal wall and expand laterally,
909
d e
with bone graft, cross-sectional and parasagittal CBCT
images immediately postoperative (c), 6 months and
3.5 years (d) after surgery show excellent healing
often occurring in the faciolingual or faciopala-
tal plane. Fractures may be either incomplete
(involving one side of the root) or complete (both
root surfaces). Complete fractures are typically
more easily detected as root segments separate.
Incomplete fractures are more difficult to detect
because they are often not visible until further
progression (American Association of Endodon-
tists 2008). Traditionally, the diagnosis of VRF
is based on both clinical examination and peri-
apical radiographic interpretation (Table 22.4)
(Fig.  22.43) and largely empirical, without evi-
dence-based data (Tsesis et al. 2010). An explor-
atory flap surgery may be necessary to confirm
and directly visualize a VRF (Meister et al.
1980). While any root-filled tooth may present
with a VRF, the most common are the maxillary
and mandibular premolars and the mesial roots of
mandibular molars (Tamse 2006).
It is important to differentiate a VRF from
similar conditions such as endodontic disease
(sinus tract draining through the gingival sulcus)
or a localized periodontal defect, since the treat-
ment and prognosis may be very different (Cohen
910 S.L. Doyle et al.

Table 22.4  Common clinical and radiographic findings associated with vertical root fractures (Testori et al. 1993;
Nicopoulou-Karayianni et al. 1997; Tamse et al. 1999a, b, 2006; Fayad et al. 2012)
Imaging
Clinical pa CBCT
• Isolated deep periodontal • “Halo or J-shaped” periapical and • Loss of bone in the mid-root area with intact
probing defect perilateral radiolucency around bone coronal and apical to the defect
the root (mid-root fracture)
• Crestally located sinus • Lateral periodontal radiolucency • Absence/loss of the entire buccal plate
tract(s) alongside the root
• Root-filled tooth • Angular radiolucency from the • Periradicular radiolucency at the terminus of a
crestal bone that terminate along post (mid apical root fracture)
the side of the root
• Radiolucency between the cortical plates and
the root surface
pa intraoral periapical radiography, CBCT cone beam computed tomography

a b c

Fig. 22.43  Parasagittal (a), axial (b), and cross-sectional (c) CBCT images of right mandibular molar demonstrating
multiple radiographic features consistent with incomplete VRF of the mesial root (confirmed after extraction)

et al. 2003). Early diagnosis and treatment is crit-
ical, since VRF can have a rapid and extensive
effect on the surrounding periodontium and osse-
ous bone (Walton et al. 1984).
Numerous ex vivo (in vitro) experiments (Has-
san et al. 2009, 2010; Melo et al. 2010; Ozer 2011;
da Silveira et al. 2013; Patel et al. 2013; Brady
et al. 2014; Junqueira et al. 2013; Jakobson et al.
2014), clinical (in vivo) studies (Edlund et al.
2011; Wang et al. 2011; Metska et al. 2012), and
case series (Bernardes et al. 2009) have compared
the efficiency of CBCT and intraoral radiography
for the detection of VRFs. These studies indicate
that CBCT has similar specificity (the ability to
detect the absence of VRF) but higher sensitivity
(the ability to detect confirmed VRF) than peri-
apical radiography, particularly when a voxel size
smaller than 0.2 mm is used (Ozer 2011; Corbella
et al. 2014). In addition, CBCT with smaller fields
of view have higher accuracy and sensitivity for
detecting VRF than larger fields of view (Bechara
et al. 2013). The type of CBCT scanner may also
affect the reproducibility and accuracy of VRF
detection (Hassan et al. 2010; Metska et al. 2012).
The presence of radiopaque obturation mate-
rials and/or posts in the root canals of endodon-
tically treated teeth may cause radiographic
artifacts such as beam hardening and streak arti-
facts that can interfere with the definitive iden-
tification of a fracture (Junqueira et al. 2013;
22  Endodontic Applications of CBCT
Corbella et al. 2014; Jakobson et al. 2014; Neves
et al. 2014). In these situations, removal of canal
materials may potentially enhance the detection
of VRFs (Ball et al. 2013).
Despite the limitations of CBCT, it can be
a valuable adjunct for the diagnosis of VRF
(Patel et al. 2015; Corbella et al. 2014; Chavda
et al. 2014; Chang et al. 2016). The usefulness
of CBCT may be more likely related to spe-
cific changes in the periradicular bone patterns
associated with an undetected VRF than in the
actual visualization of the fracture in the root
structure. The authors of a recent meta-analysis
of the role of CBCT in the diagnosis of VRF
stated that CBCT scans showed better sensitiv-
ity and specificity than periapical radiography in
unfilled teeth, especially when with a voxel size
of 0.2 mm. CBCT showed low pooled sensitivity
a b
c d
Fig. 22.44  Periapical image (a) of endodontically treated
maxillary right first molar with intermittent symptoms.
Sagittal (b), axial (c), and cross-sectional (d) CBCT
images demonstrate furcal perforation due to misguided
911
in detecting VRF in root-filled teeth (Talwar et al.
2016). In regard to the use of CBCT for VRF, the
AAE and AAOMR (2015) state:
Limited FOV CBCT should be considered the
imaging modality of choice if clinical examination
and 2-D intraoral radiography are inconclusive in
the detection of VRF.
Further research is needed to investigate the
effect of changes in periradicular bone patterns,
the experience of observers, the resolution of the
CBCT images, and image interval thickness in
the radiographic diagnosis of VRF (Cohenca and
Shemesh 2015).
Perforation
Iatrogenic root perforations are complications
that may occur during endodontic treatment
(Fig. 22.44) or subsequent post preparation or pin
access during attempt to negotiate the MB2 canal and
mesial vertical marginal alveolar defect. The patient opted
for extraction and symptoms resolved
912
insertion (Fig. 22.45). Treatment involves imme-
diate sealing of the perforation and prevention of
infection using nonsurgical, surgical, or a combi-
nation of approaches. Prognosis depends on the
time of occurrence, size, location, and material
used to repair the perforation (Fuss and Trope
1996; Siew et al. 2015).
Radiographic detection of perforations involv-
ing the labial or lingual root surface is challeng-
ing, even using a tube shift technique (Goerig
and Neaverth 1987). CBCT may facilitate in
the determination of the nature of a perforation,
a b
c d
Fig. 22.45  Periapical image (a) of a patient who presents
with a low-grade ache and mild tenderness to percussion
associated with the left second mandibular premolar.
S.L. Doyle et al.
prognosis, and subsequent treatment (Young
2007; Shemesh et al. 2011; Kamburoğlu et al.
2015). Dynamic visualization by axial image
scrolling or “map reading” (Bueno et al. 2011)
may provide an optimal interpretation strategy.
In regard to detection of endodontic complica-
tions, the AAE and AAOMR (2015) state:
Limited FOV CBCT should be the imaging modal-
ity of choice for nonsurgical retreatment to assess
endodontic treatment complications, such as over-
extended root canal obturation material, sepa-
rated endodontic instruments, and localization of
perforations.
Sagittal (b), cross-sectional (c), and axial (d) CBCT
images demonstrate an area of low density lingually and
perforation of a restorative pin
22  Endodontic Applications of CBCT
22.3.5.3 Endodontic Retreatment
Options: Nonsurgical
and Surgical
Despite endodontic retention rates up to 97%
(Salehrabi and Rotstein 2004; Chen et al. 2007;
Lazarski et al. 2001; Ng et al. 2010; de Chevigny
et al. 2008), some root-filled teeth may require
additional procedures to address residual post-
treatment apical periodontitis. The AAE and
AAOMR (2015) state:
Limited FOV CBCT should be the imaging modal-
ity of choice when evaluating the nonhealing of
previous endodontic treatment to help determine
the need for further treatment, such as nonsurgical,
surgical or extraction.
Causes for residual AP include additional
canal(s), variations in canal morphology, poor
obturation, incorrect position of intracanal post,
perforations, resorptions, and size and location of
apical lesion (Cohenca and Shemesh 2015). Non-
surgical retreatment is often the first choice if the
etiology can be addressed (Gorni and Gagliani
2004) with selective root retreatment (Nudera
2015) proposed as a conservative option.
Endodontic microsurgery has evolved to pro-
vide a predictable option to retain diseased teeth
(Niemczyk 2010; Setzer et al. 2010; Torabinejad
et al. 2015). In regard to surgical planning for
microsurgery, the AAE and AAOMR (2015) state:
Limited FOV CBCT should be considered as the
imaging modality of choice for presurgical treat-
ment planning to localize root apex/apices and
to evaluate the proximity to adjacent anatomical
structures.
In this regard, CBCT imaging should involve
assessment of the following (Tsurumachi and
Honda 2007; Mao and Neelakantan 2014):
• Positional relationship of root apices and peri-
apical lesions with critical vital anatomical
structures such as the mandibular canal (Kim
et al. 2010; Kovisto et al. 2011; Bornstein
et al. 2011), mental foramen (von Arx et al.
2013; Carruth et al. 2015), and the maxillary
sinus (Rigolone et al. 2003; Low et al. 2008;
Bornstein et al. 2012; Kurt et al. 2014).
913
• Thickness and architecture of the cortical
plate and the cancellous bone.
• Inclination of roots.
• Root canal morphology.
• Untreated root canals.
• Cracks and fractures.
• Location and extent of periapical pathoses
(Nakata et al. 2006; Patel et al. 2012a).
22.3.5.4 Dental Implant Therapy
The predictability of dental implant therapy has
had profound effects on endodontic, periodontal,
and prosthodontic treatment planning for the reha-
bilitation of edentulous spaces and for teeth with an
unfavorable prognosis. With appropriate usage and
case selection, implant dentistry provides a viable
option for the replacement of missing teeth (Ameri-
can Association of Endodontists 2015; Iqbal and
Kim 2007). Radiographic examination, particularly
cross-sectional imaging, is crucial for the assessment
of available bone volume (Tyndall and Kohltfarber
2012). Limited FOV CBCT should be considered as
the imaging modality of choice for surgical place-
ment of implants (AAOMR/AAE 2015).
Conclusion
Radiography is an essential imaging adjunct
for diagnosis, treatment planning, manage-
ment and follow-up assessment of pulpal and
periradicular disease. CBCT imaging over-
comes many of the limitations of intraoral
radiography, offering significant benefits in all
phases of endodontic therapy in many clinical
situations. With judicious use, CBCT influ-
ences how clinicians diagnose, treatment plan,
and treat patients. Future CBCT research
should be directed towards improvements in
diagnostic capabilities and assessment of clin-
ical efficacy towards more predictable man-
agement of patients with endodontic disease.
Acknowledgments The authors wish to thank Dr.
Scott Hetz, Dr. William Nudera, Dr. David Landwehr,
Dr. Michael Ribera and all partners at Metropolitan
Endodontics (Eden Prairie, Inver Grove Heights,
Woodbury and Burnsville, Minnesota USA) for their sup-
port in the development of this chapter.
914
References
Abella F, Mercadé M, Duran-Sindreu F, Roig M (2011)
Managing severe curvature of radix entomolaris:
three-dimensional analysis with cone beam computed
tomography. Int Endod J 44:876–885
Abella F, Patel S, Duran-Sindreu F, Mercad M, Bueno
R, Roig M (2012) Evaluating the periapical status of
teeth with irreversible pulpitis by using cone-beam
computed tomography scanning and periapical radio-
graphs. J Endod 38:1588–1591
Abella F, Patel S, Durán-Sindreu F, Mercadé M, Bueno R,
Roig M (2014) An evaluation of the periapical status
of teeth with necrotic pulps using periapical radiogra-
phy and cone-beam computed tomography. Int Endod
J 47:387–396
Abella F, Teixidó LM, Patel S, Sosa F, Duran-Sindreu F,
Roig M (2015) Cone-beam computed tomography
analysis of the root canal morphology of maxillary
first and second premolars in a Spanish population. J
Endod 41:1241–1247
Ahlowalia MS, Patel S, Anwar HM, Cama G, Austin RS,
Wilson R, Mannocci F (2013) Accuracy of CBCT
for volumetric measurement of simulated periapical
lesions. Int Endod J 46:538–546
American Association of Endodontists (2008) Colleagues
for Excellence. Cracking the cracked tooth code:
detection and treatment of various longitudinal
fractures
American Association of Endodontists (2011) Colleagues
for Excellence. Cone beam-computed tomography in
endodontics
American Association of Endodontists (2012) Glossary
of endodontic terms. American Association of
Endodontists, Chicago
American Association of Endodontists (2015) Colleagues
for Excellence. Treatment planning: retention of the
natural dentition and the replacement of missing teeth
American Association of Endodontists; American
Academy of Oral and Maxillofacial Radiology (2011)
Use of cone-beam computed tomography in endodon-
tics joint position statement of the American Association
of Endodontists and the American Academy of oral
and maxillofacial radiology. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 111:234–237
American Association of Endodontists; American
Academy of Oral and Maxillofacial Radiology (2015)
Use of cone-beam computed tomography in endodon-
tics 2015 update AAE and AAOMR joint position
statement. J Endod 41:1393–1396
Andreasen JO (1985) External root resorption: its implica-
tions in dental traumatology, paedodontics, periodontics,
orthodontics and endodontics. Int J Endod 8:109–118
Andreasen J (1989) Prognosis of root-fractured perma-
nent incisors: prediction of healing modalities. Endod
Dent Traumatol 5:11–22
Andreasen JO, Andreasen FM (1994) Classification, etiol-
ogy and epidemiology. In: Andreasen JO, Andreasen FM
(eds) Textbook and color atlas of traumatic injuries to the
teeth, 3rd edn. Munksgaard, Copenhagen, pp 151–216
S.L. Doyle et al.
Andreasen FM, Vestergaard Pedersen B (1985) Prognosis
of luxated permanent teeth—the development of pulp
necrosis. Endod Dent Traumatol 1:207–220
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM
(1995) Replantation of 400 avulsed permanent inci-
sors. 4. Factors related to periodontal ligament heal-
ing. Endod Dent Traumatol 11:76–89
Andreasen FM, Andreasen JO, Cvek M (2007) Root frac-
tures. In: Andreasen JO, Andreasen FM, Andersson L
(eds) Textbook and color atlas of traumatic injuries to the
teeth. Munksgaard, Kopenhagen, Denmark, pp 337–371
Angelopoulos C (2008) Cone beam tomographic imaging
anatomy of the maxillofacial region. Dent Clin N Am
52:731–752
Aribandi M, McCoy VA, Bazan C III (2007) Imaging fea-
tures of invasive and noninvasive fungal sinusitis: a
review. Radiographics 27:1283–1296
Bakland LK, Andreasen JO (2004) Dental traumatology:
essential diagnosis and treatment planning. Endod
Topics 7:14–34
Ball RL, Barbizam JV, Cohenca N (2013) Intraoperative
endodontic applications of cone-beam computed
tomography. J Endod 39:548–557
Baratto Filho F, Zaitter S, Haragushiku GA, de Campos
EA, Abuabara A, Correr GM (2009) Analysis of the
internal anatomy of maxillary first molars by using
different methods. J Endod 35(3):337–342
Barbat J, Messer HH (1998) Detectability of artificial
periapical lesions using direct digital and conventional
radiography. J Endod 24:837–842
Barthel CR, Zimmer S, Trope M (2004) Relationship of
radiologic and histologic signs of inflammation in
human root-filled teeth. J Endod 30:75–79
Basrani B (2012) Radiographic considerations during the
endodontic treatment. In: Basrani B (ed) Endodontic
radiology. Wiley, Ames, Iowa, pp 193–217
Bauer WH (1943) Maxillary sinus of dental origin. Am J
Orthod Oral Surg 29:133–151
Bauman R, Scarfe W, Clark S, Morelli J, Scheetz J, Farman
A (2011) Ex vivo detection of mesiobuccal canals in
maxillary molars using CBCT at four different isotro-
pic voxel dimensions. Int Endod J 44:752–758
Bechara B, McMahan CA, Noujeim M, Faddoul T, Moore
WS, Teixeira FB, Geha H (2013) Comparison of cone
beam CT scans with enhanced photostimulated phos-
phor plate images in the detection of root fracture of
endodontically treated teeth. Dentomaxillofac Radiol
42:20120404
Bender IB (1982) Factors influencing the radiographic
appearance of bony lesions. J Endod 8:161–170
Bender IB, Seltzer S (1961a) Roentgenographic and direct
observation of experimental lesions in bone. Part 1. J
Am Dent Assoc 62:152–160
Bender IB, Seltzer S (1961b) Roentgenographic and
direct observation of experimental lesions in bone.
Part 2. J Am Dent Assoc 62:708–716
Bernardes RA, de Moraes IG, Duarte MA, Azevedo BC,
de Azevedo JR, Bramante CM (2009) Use of cone-­
beam volumetric tomography in the diagnosis of root
fractures. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 108:270–277
22  Endodontic Applications of CBCT
Bernardes RA, de Paulo RS, Pereira LO, Duarte MA,
Ordinola-Zapata R, de Azevedo JR (2012) Comparative
study of cone beam computed tomography and intraoral
periapical radiographs in diagnosis of lingual-simulated
external root resorptions. Dental Traumatol 28:268–272
Bhaskar SN (1968) Oral pathology in the dental office:
survey of 20,575 biopsy specimens. J Am Dent Assoc
76:761–766
Blattner TC, Goerge N, Lee CC, Kumar V, Yelton CDJ
(2010) Efficacy of CBCT as a modality to accurately
identify the presence of second mesiobuccal canals
in maxillary first and second molars: a pilot study. J
Endod 36:867–870
Borges AH, Mamede-Neto I, Volpato LE, Pedro FL,
Bueno MR, Estrela C (2014) Using cone beam com-
puted tomography images to diagnose multiple taur-
odontisms. Gen Dent 62:20–22
Bornstein MM, Wölner-Hanssen AB, Sendi P, von Arx
T (2009) Comparison of intraoral radiography and
limited cone beam computed tomography for the
assessment of root-fractured permanent teeth. Dent
Traumatol 25:571–577
Bornstein MM, Lauber R, Sendi P, von Arx T (2011)
Comparison of periapical radiography and limited
cone-beam computed tomography in mandibular
molars for analysis of anatomical landmarks before
apical surgery. J Endod 37:151–157
Bornstein MM, Wasmer J, Sendi P, Janner SF, Buser D,
von Arx T (2012) Characteristics and dimensions of
the Schneiderian membrane and apical bone in maxil-
lary molars referred for apical surgery: a comparative
radiographic analysis using limited cone beam com-
puted tomography. J Endod 38:51–57
Brady E, Mannocci F, Brown J, Wilson R, Patel S (2014)
A comparison of cone beam computed tomography
and periapical radiography for the detection of vertical
root fractures in nonendodontically treated teeth. Int
Endod J 47:735–746
Brynolf I (1970) Roentgenologic periapical diagnosis.
II. One, two or more roentgenograms? Sven Tandlak
Tidskr 63:345–350
Bueno MR, Estrela C, Figueiredo JAP, Azevedo BC
(2011) Map-reading strategy to diagnose root perfo-
rations near metallic intracanal posts by using cone
beam computed tomography. J Endod 37:85–90
Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS (2002)
Effect of magnification on locating the MB2 canal in
maxillary molars. J Endod 28:324–327
Calişkan MK, Türkün M (1997) Prognosis of permanent
teeth with internal resorption: a clinical review. Endod
Dent Traumatol 13:75–81
Capar ID, Ertas H, Arslan H, Tarim Ertas E (2015) A
retrospective comparative study of cone-beam com-
puted tomography versus rendered panoramic images
in identifying the presence, types, and characteristics
of dens invaginatus in a Turkish population. J Endod
41:473–478
Chang E, Lam E, Shah P, Azarpazhooh A (2016) Cone-
beam computed tomography for detecting vertical root
fractures in Endodontically treated teeth: a systematic
review. J Endod 42(2):177–189
915
Chavda R, Mannocci F, Andiappan M, Patel S (2014)
Comparing the in vivo diagnostic accuracy of digi-
tal periapical radiography with cone-beam computed
tomography for the detection of vertical root fracture.
J Endod 40:1524–1529
Chen SC, Chueh LH, Hsiao CK et al (2007) An epidemio-
logic study of tooth retention after nonsurgical end-
odontic treatment in a large population in Taiwan. J
Endod 33:226–229
Christiansen R, Kirkevang L-L, Gotfredsen E, Wenzel
A (2009) Periapical radiography and cone beam
computed tomography for assessment of the periapi-
cal bone defect 1 week and 12 months after root-end
resection. Dentomaxillofac Radiol 38:531–536
Cleghorn BM, Christie WH, Dong CC (2006) Root and
root canal morphology of the human permanent
maxillary first molar: a literature review. J Endod
32:813–821
Cohen S, Blanco L, Berman L (2003) Vertical root frac-
tures—clinical and radiographic diagnosis. J Am Dent
Assoc 134:434–441
Cohenca N, Shemesh H (2015) Clinical applications of
cone beam computed tomography in endodontics: a
comprehensive review. Quintessence Int 46:465–480
Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM
(2007a) Clinical indications for digital imaging in
dento-alveolar trauma. Part 1: traumatic injuries.
Dental Traumatol 23:95–104
Cohenca N, Simon JH, Mathur A, Malfaz JM (2007b)
Clinical indications for digital imaging in dento-­
alveolar trauma. Part 2: root resorption. Dent
Traumatol 23:105–113
Corbella S, Del Fabbro M, Tamse A, Rosen E, Tsesis I,
Taschieri S (2014) Cone beam computed tomography
for the diagnosis of vertical root fractures: a system-
atic review of the literature and meta-analysis. Oral
Surg Oral Med Oral Pathol Oral Radiol 118:593–602
Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler
WG (2007) Endodontic applications of cone-­beam volu-
metric tomography. J Endod 33:1121–1132
Cvek M, Andreasen JO, Borum MK (2001) Healing of
208 intra-alveolar root fractures in patients aged 7-17
years. Dent Traumatol 17:53–62
Cvek M, Tsilingaridis G, Andreasen JO (2008) Survival
of 534 incisors after intra-alveolar root fracture in
patients aged 7–17 years. Dent Traumatol 24:379–387
D’Addazio PS, Campos CN, Ozcan M, Teixeira HGC,
Passoni RM, Carvalho ACP (2011) A comparative
study between cone-beam computed tomography and
periapical radiographs in the diagnosis of simulated
endodontic complications. Int Endod J 44:218–224
da Silveira HL, Silveira HE, Liedke GS, Lermen CA,
Dos Santos RB, de Figueiredo JA (2007) Diagnostic
ability of computed tomography to evaluate exter-
nal root resorption in vitro. Dentomaxillofac Radiol
36:393–396
da Silveira PF, Vizzotto MB, Liedke GS, da Silveira HL,
Montagner F, da Silveira HE (2013) Detection of
vertical root fractures by conventional radiographic
examination and cone beam computed tomography-
dan in vitro analysis. Dent Traumatol 29:41–46
916
Dang H, Stayman JW, Sisniega A, Xu J, Zbijewski
W, Wang X, Foos DH, Aygun N, Koliatsos VE,
Siewerdsen JH (2015) Statistical reconstruction for
cone-beam CT with a post-artifact-correction noise
model: application to high-quality head imaging. Phys
Med Biol 60:6153–6175
de Chevigny C, Dao TT, Basrani BR et al (2008) Treatment
outcome in endodontics: the Toronto study—phase 4:
initial treatment. J Endod 34:258–263
de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C,
Cohenca N (2010) Root anatomy and canal configura-
tion of the permanent mandibular first molar: a sys-
tematic review. J Endod 36:1919–1931
de Paula-Silva FW, Wu M-K, Leonardo MR, da Silva LA,
Wesselink PR (2009a) Accuracy of periapical radiog-
raphy and cone-beam computed tomography scans in
diagnosing apical periodontitis using histopathologi-
cal findings as a gold standard. J Endod 35:1009–1012
de Paula-Silva FW, Santamaria M, Leonardo MR,
Consolaro A, da Silva LA (2009b) Cone-beam
computerized tomographic, radiographic, and his-
tologic evaluation of periapical repair in dogs’ post-­
endodontic treatment. Oral Surg Oral Med Oral Path
Oral Radiol Endod 108:796–805
Domark JD, Hatton JF, Benison RP, Hildebolt CF (2013)
An ex vivo comparison of digital radiography and
cone-beam and micro computed tomography in the
detection of the number of canals in the mesiobuccal
roots of maxillary molars. J Endod 31:901–905
Durack C, Patel S, Davies J, Wilson R, Mannocci F (2011)
Diagnostic accuracy of small volume cone beam com-
puted tomography and intraoral periapical radiography
for the detection of simulated external inflammatory
root resorption. Int Endod J 44:136–147
Edlund M, Nair MK, Nair UP (2011) Detection of vertical
root fractures by using cone-beam computed tomogra-
phy: a clinical study. J Endod 37:768–772
Ee J, Fayad MI, Johnson BR (2014) Comparison of end-
odontic diagnosis and treatment planning decisions
using cone-beam volumetric tomography versus peri-
apical radiography. J Endod 40:910–916
Ellis RG, Davey KW (1970) The classification and treat-
ment of injuries to the teeth of children, 5th edn. Year
Book Medical Publishers, Inc, Chicago
Engström B, Ericson S (1964) Roentgenological-clinical
follow-up study of perforations of the maxillary sinus
via root canals. Od Revy 15:404–413
Estrela C, Bueno MR, Sousa-Neto MD, Pécora JD (2008a)
Method for determination of root curvature radius
using cone-beam computed tomography images. Braz
Dent J 19:114–118
Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo
JR (2008b) Accuracy of cone beam computed tomog-
raphy and panoramic and periapical radiography for
detection of apical periodontitis. J Endod 34:273–279
Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pécora
JD (2008c) A new periapical index based on cone
beam computed tomography. J Endod 34:1325–1331
Estrela C, Reis Bueno M, Alencar AHG et al (2009)
Method to evaluate inflammatory root resorption by
S.L. Doyle et al.
using cone beam computed tomography. J Endod
35:1491–1497
European Commission (2012) Radiation protection no
172 cone beam CT for dental and maxillofacial radiol-
ogy (evidence-based guidelines). The SEDENTEXCT
Project, Luxembourg
European Society of Endodontology (2006) Quality
guidelines for endodontic treatment: consensus report
of the European Society of Endodontology. Int Endod
J 39:921–930
European Society of Endodontology, Patel S, Durack C,
Abella F, Roig M, Shemesh H, Lambrechts P, Lemberg
K (2014) European Society of Endodontology posi-
tion statement: the use of CBCT in endodontics. Int
Endod J 47:502–504
Ezoddini AF, Sheikhha MH, Ahmadi H (2007) Prevalence
of dental developmental anomalies: a radiographic
study. Community Dent Health 24:140–144
Fayad MI, Ashkenaz PJ, Johnson BR (2012) Different
representations of vertical root fractures detected
by cone-beam volumetric tomography: a case series
report. J Endod 38:1435–1442
Flores MT, Andersson L, Andreasen JO et al (2007)
Guidelines for the management of traumatic den-
tal injuries: I—fractures and luxations of permanent
teeth. Dent Traumatol 23:66–71
Fogel HM, Peikoff MD, Christie WH (1994) Canal con-
figuration in the mesiobuccal root of the maxillary first
molar: a clinical study. J Endod 20:135–137
Folk RB, Thorpe JR, McClanahan SB, Johnson JD,
Strother JM (2005) Comparison of two different
direct digital radiography systems for the ability to
detect artificially prepared periapical lesions. J Endod
31:304–306
Friedman S (2002) Prognosis of initial endodontic ther-
apy. Endod Topics 2:59–98
Fryback DG, Thornbury JR (1991) The efficacy of diag-
nostic imaging. Med Decis Mak 11:88–94
Fuss Z, Trope M (1996) Root perforations: classification
and treatment choices based on prognostic factors.
Endod Dent Traumatol 12:255–264
Gartner AH, Mack T, Somerlott RG, Walsh LC (1976)
Differential diagnosis of internal and external root
resorption. J Endod 2:329–334
Geist JR, Katz JO (1990) The frequency and distribution
of idiopathic osteosclerosis. Oral Surg Oral Med Oral
Pathol 69:388–393
Giardino L, Pontieri F, Savoldi E, Tallarigo F (2006)
Aspergillus mycetoma of the maxillary sinus second-
ary to overfilling a root canal. J Endod 32:692–694
Goerig AC, Neaverth EJ (1987) A simplified look at the
buccal object rule in endodontics. J Endod 13:570–572
Goldman M, Pearson AH, Darzenta N (1972) Endodontic
success—who’s reading the radiograph? Oral Surg
Oral Med Oral Pathol 33:432–437
Goldman M, Pearson AH, Darzenta N (1974) Reliability
of radiographic interpretations. Oral Surg Oral Med
Oral Pathol 38:287–293
Gorni FG, Gagliani MM (2004) The outcome of endodon-
tic retreatment: a 2-yr follow-up. J Endod 30:1–4
22  Endodontic Applications of CBCT
Grahnhen H, Lindahal B, Omnell K (1959) Dens invagi-
natus, part I: a clinical roentgenological and geneti-
cal study of permanent upper lateral incisors. Odontol
Rev 10:115–137
Green TL, Walton RE, Clark JM, Maixner D (2013)
Histologic examination of condensing osteitis in
cadaver specimens. J Endod 39:977–979
Gröndahl H-G, Huumonen S (2004) Radiographic mani-
festations of periapical inflammatory lesions. Endod
Topics 8:55–67
Guo J, Simon JH, Sedghizadeh P, Soliman ON, Chapman
T, Enciso R (2013) Evaluation of the reliability and
accuracy of using cone-beam computed tomography
for diagnosing periapical cysts from granulomas. J
Endod 39:1485–1490
Haapasalo M, Endal U (2006) Internal inflammatory
root resorption: the unknown resorption of the tooth.
Endod Topics 14:60–79
Hahn W, Fricke-Zech S, Fricke J, Gruber RM, Dullin
C, Zapf A, Hannig C, Kubein-Meesenburg D, Sadat-­
Khonsari R (2009) Detection and size differentiation
of simulated tooth root defects using flat-panel volume
computerized tomography (fpVCT). Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 107:272–278
Hamasha AA, Alomari QD (2004) Prevalence of dens
invaginatus in Jordanian adults. Int Endod J 37:307–310
Harar RP, Chadha NK, Rogers G (2007) Are maxillary
mucosal cysts a manifestation of inflammatory sinus
disease? J Laryngol Otol 121:751–754
Hassan B, Metska ME, Ozok AR, van der Stelt P,
Wesselink PR (2009) Detection of vertical root frac-
tures in endodontically treated teeth by a cone beam
computed tomography scan. J Endod 35:719–722
Hassan B, Metska ME, Ozok AR, van der Stelt P,
Wesselink PR (2010) Comparison of five cone beam
computed tomography systems for the detection of
vertical root fractures. J Endod 36:126–129
Heithersay GS (1999a) Clinical, radiographic, and histo-
pathological features of invasive cervical resorption.
Quintessence Int 30:27–37
Heithersay GS (1999b) Invasive cervical resorp-
tion: an analysis of potential predisposing factors.
Quintessence Int 30:83–95
Heithersay GS (2004) Invasive cervical resorption. Endod
Topics 7:73–92
Horning GM, Cohen ME, Neils TA (2000) Buccal alveolar
exostoses: prevalence, characteristics, and evidence for
buttressing bone formation. J Periodontol 71:1032–1042
Hovland EJ, Block RM (1977) Nonrecognition and sub-
sequent endodontic treatment of dens invaginatus. J
Endod 3:360–362
Hülsmann M (1997) Dens invaginatus: aetiology, classifi-
cation, prevalence, diagnosis, and treatment consider-
ations. Int Endod J 30:79–90
Huumonen S, Ørstavik D (2002) Radiological aspects of
apical periodontitis. Endod Topics 7:3–25
Huumonen S, Kvist T, Gröndahl K, Molander A (2006)
Diagnostic value of computed tomography in re-­
treatment of root fillings in maxillary molars. Int
Endod J 39:827–833
917
Iikubo M, Kobayashi K, Mishima A et al (2009) Accuracy
of intraoral radiography, multi- detector helical CT,
and limited cone-beam CT for the detection of hori-
zontal tooth root fracture. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 108:70–74
International Association of Dental Traumatology (2012)
International Association of Dental Traumatology
guidelines for the management of traumatic dental
injuries: 1. Fractures and luxations of permanent teeth.
Dental Traumatol 28, 2–12
Iqbal MK, Kim S (2007) For teeth requiring endodon-
tic treatment, what are the differences in outcomes
of restored endodontically treated teeth compared to
implant-supported restorations? Int J Oral Maxillofac
Implants 22(Suppl):96–116
Jafarzadeh H, Abbott PV (2007) Dilaceration: review of
an endodontic challenge. J Endod 33:1025–1030
Jafarzadeh H, Azarpazhooh A, Mayhall JT (2008)
Taurodontism: a review of the condition and endodon-
tic treatment challenges. Int Endod J 41:375–388
Jainkittivong A, Langlais RP (2000) Buccal and pala-
tal exostoses: prevalence and concurrence with tori.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
90:48–53
Jakobson SJ, Westphalen VP, Silva Neto UX, Fariniuk
LF, Schroeder AG, Carneiro E (2014) The influ-
ence of metallic posts in the detection of vertical
root fractures using different imaging examinations.
Dentomaxillofac Radiol 43:20130287
Janner SF, Jeger FB, Lussi A, Bornstein MM (2011)
Precision of endodontic working length measure-
ments: a pilot investigation comparing cone-beam
computed tomography scanning with standard mea-
surement techniques. J Endod 37:1046–1051
Jeger FB, Janner SF, Bornstein MM, Lussi A (2012)
Endodontic working length measurement with pre-
existing cone-beam computed tomography scanning:
a prospective, controlled clinical study. J Endod
38:884–888
John V (2008) Non-surgical management of infected type
III dens invaginatus with vital surrounding pulp using
contemporary endodontic techniques. Aust Endod J
34:4–11
Junqueira RB, Verner FS, Campos CN, Devito KL, do
Carmo AM (2013) Detection of vertical root fractures
in the presence of intracanal metallic post: a compari-
son between periapical radiography and cone-beam
computed tomography. J Endod 39:1620–1622
Kamburoğlu K, Kursun S, Yuksel S, Oztas B (2011)
Observer ability to detect ex vivo simulated inter-
nal or external cervical root resorption. J Endod 37:
168–175
Kamburoğlu K, Yeta EN, Yılmaz F (2015) An ex vivo
comparison of diagnostic accuracy of cone-beam
computed tomography and periapical radiogra-
phy in the detection of furcal perforations. J Endod
41:696–702
Kanagalingam J, Bhatia K, Georgalas C, Fokkens W,
Miszkiel K, Lund VJ (2009) Maxillary mucosal cyst is
not a manifestation of rhinosinusitis: results of a pro-
918
spective three-dimensional CT study of ophthalmic
patients. Laryngoscope 119:8–12
Kaya S, Yavuz I, Uysal I, Akkus Z (2012) Measuring bone
density in healing periapical lesions by using cone
beam computed tomography: a clinical investigation.
J Endod 38:28–31
Khongkhunthian P, Reichart PA (2001) Aspergillosis of
the maxillary sinus as a complication of overfilling
root canal material into the sinus: report of two cases.
J Endod 27:476–478
Kim TS, Caruso JM, Christensen H, Torabinejad M
(2010) A comparison of cone-beam computed tomog-
raphy and direct measurement in the examination of
the mandibular canal and adjacent structures. J Endod
36:1191–1194
Kishen A (2006) Mechanisms and risk factors for fracture
predilection in endodontically treated teeth. Endod
Top 13:57–83
Kovisto T, Ahmad M, Bowles WR (2011) Proximity
of the mandibular canal to the tooth apex. J Endod
37:311–315
Kruse C, Spin-Neto R, Wenzel A, Kirkevang LL (2015)
Cone beam computed tomography and periapical
lesions: a systematic review analysing studies on diag-
nostic efficacy by a hierarchical model. Int Endod J
48:815–828
Kulild JC, Peters DD (1990) Incidence and configuration
of canal systems in the mesiobuccal root of maxillary
first and second molars. J Endod 16:311–317
Kurt SN, Üstün Y, Erdogan Ö, Evlice B, Yoldas O, Öztunc
H (2014) Outcomes of periradicular surgery of maxil-
lary first molars using a vestibular approach: a pro-
spective, clinical study with one year of follow-up. J
Oral Maxillofac Surg 72:1049–1061
Laatikainen T, Ranta R (1996) Taurodontism in twins
with cleft lip and/or palate. Eur J Oral Sci 104(2(part
1)):82–86
Lazarski MP, Walker WA III, Flores CM et al (2001)
Epidemiological evaluation of the outcomes of non-
surgical root canal treatment in a large cohort of
insured dental patients. J Endod 27:791–796
Lee S-J, Messer HH (1986) Radiographic appearance of
artificially prepared periapical lesions confined to can-
cellous bone. Int J Endod 19:64–72
Legert KG, Zimmerman M, Stierna P (2004) Sinusitis of
odontogenic origin: pathophysiological implications
of early treatment. Acta Otolaryngol 124:655–663
Liang Y-H, Li G, Wesselink PR, Wu M-K (2011)
Endodontic outcome predictors identified with peri-
apical radiographs and cone-beam computed tomog-
raphy scans. J Endod 37:326–331
Liedke GS, da Silveira HE, da Silveira HL, Dutra V,
de Figueiredo JA (2009) Influence of voxel size in
the diagnostic ability of cone beam tomography to
evaluate simulated external root resorption. J Endod
35:233–235
Llena C, Fernandez J, Ortolani PS, Forner L (2014) Cone-­
beam computed tomography analysis of root and canal
morphology of mandibular premolars in a Spanish
population. Imaging Sci Dent 4:221–227
S.L. Doyle et al.
Paes da Silva Ramos Fernandes LM, Rice D, Ordinola-­
Zapata R, Alvares Capelozza AL, Bra-mante CM,
Jaramillo D, Christensen H (2014) Detection of vari-
ous anatomic patterns of root canals in mandibular
incisors using digital periapical radiography, 3 cone-­
beam com-puted tomographic scanners, and micro-­
computed tomographic imaging. J Endod 40:42–45
Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl
HG (2007) Limited cone-beam CT and intraoral radi-
ography for the diagnosis of periapical pathology.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
103:114–119
Low KM, Dula K, Bürgin W, von Arx T (2008)
Comparison of periapical radiography and limited
cone-beam tomography in posterior maxillary teeth
referred for apical surgery. J Endod 34:557–562
Lu Y, Liu Z, Zhang L, Zhou X, Zheng Q, Duan X, Zheng
G, Wang H, Huang D (2012) Associations between
maxillary sinus mucosal thickening and apical peri-
odontitis using cone-beam computed tomography
scanning: a retrospective study. J Endod 38:1069–1074
MacDonald-Jankowski DS (1999) Idiopathic osteo-
sclerosis in the jaws of Britons and of the Hong
Kong Chinese: radiology and systematic review.
Dentomaxillofac Radiol 28:357–363
Maddalone M, Gagliani M (2003) Periapical endodon-
tic surgery: a 3-year follow-up study. Int Endod J
36:193–198
Maini A, Durning P, Drage N (2008) Resorption: within or
without? The benefit of cone-beam computed tomog-
raphy when diagnosing a case of an internal/external
resorption defect. Br Dent J 204:135–137
Malliet M, Bowles WR, McClanahan SL, John MT,
Ahmad M (2011) Cone-beam computed tomography
evaluation of maxillary sinusitis. J Endod 37:753–757
Maloney PL, Doku HC (1968) Maxillary sinusitis of
odontogenic origin. J Can Dent Assoc 34:591–603
Mao T, Neelakantan P (2014) Three-dimensional imag-
ing modalities in endodontics. Imaging Sci Dent
44:177–183
Marmary Y, Koter T, Heling I (1999) The effect of peri-
apical rarefying osteitis on cortical and cancellous
bone. A study comparing conventional radiographs
with computed tomography. Dentomaxillofac Radiol
28:267–271
Martinez-Lozano MA, Forner-Navarro L, Sanchez-Cortes
JL (1999) Analysis of radiologic factors in determin-
ing premolar root canal systems. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 88:719–722
Martins JN, Marques D, Mata A, Caramês J (2014)
Clinical efficacy of electronic apex locators: system-
atic review. J Endod 40:759–777
Matherne RP, Angelopoulos C, Kulild JC, Tira D (2008)
Use of cone-beam computed tomography to identify
root canal systems in vitro. J Endod 34:87–89
McClammy TV (2014) Endodontic applications of
cone beam computed tomography. Dent Clin N Am
58:545–559
Mehra P, Murad H (2004) Maxillary sinus disease of odon-
togenic origin. Otolaryngol Clin N Am 37:347–364
22  Endodontic Applications of CBCT
Meister F, Lommel TJ, Gerstein H (1980) Diagnosis and
possible causes of vertical root fractures. Oral Surg
Oral Med Oral Pathol 49:243–253
Melo SL, Bortoluzzi EA, Abreu M Jr, Correa LR, Correa
M (2010) Diagnostic ability of a cone-beam computed
tomography scan to assess longitudinal root fractures
in prosthetically treated teeth. J Endod 36:1879–1882
Metska ME, Aartman IH, Wesselink PR, Ozok AR (2012)
Detection of vertical root fractures in vivo in endodon-
tically treated teeth by cone-beam computed tomogra-
phy scans. J Endod 38:1344–1347
Metska ME, Parsa A, Aartman IH, Wesselink PR, Ozok
AR (2013) Volumetric changes in apical radiolucen-
cies of endodontically treated teeth assessed by cone-
beam computed tomography 1 year after orthograde
retreatment. J Endod 39:1504–1509
Metska ME, Liem VM, Parsa A, Koolstra JH, Wesselink
PR, Ozok AR (2014) Cone-beam computed tomo-
graphic scans in comparison with periapical radio-
graphs for root canal length measurement: an in situ
study. J Endod 40:1206–1209
Michetti J, Maret D, Mallet J-P, Diemer F (2010) Validation
of cone beam computed tomography as a tool to
explore root canal anatomy. J Endod 36:1187–1190
Mota de Almeida FJ, Knutsson K, Flygare L (2014a)
The effect of cone beam CT (CBCT) on therapeutic
decision-­ making in endodontics. Dentomaxillofac
Radiol 43:20130137
Mota de Almeida FJ, Knutsson K, Flygare L (2014b)
The impact of cone beam computed tomography
on the choice of endodontic diagnosis. Int Endod J
48:564–572
Nair PNR (2003) Non-microbial etiology: periapical cysts
sustain post-treatment apical periodontitis. Endod
Topics 6:96–113
Nair PN (2004) Pathogenesis of apical periodontitis and
the causes of endodontic failures. Crit Rev Oral Biol
Med 15:348–381
Nair PNR (2006) On the causes of persistent apical peri-
odontitis: a review. Int Endod J 39:249–281
Nair MK, Nair UP (2007) Digital and advanced imaging
in endodontics: a review. J Endod 33:1–6
Nair PNR, Sjögren U, Schumacher E, Sundqvist G (1993)
Radicular cysts affecting a root-filled human tooth:
a long-term post-treatment follow-up. Int Endod J
26:225–233
Nair M, Levin M, Nair U (2015) Chapter 2. Radiographic
interpretation. In: Hargreaves KM, Berman L (eds)
Cohen’s pathways of the pulp, 11th edn. Mosby
Elsevier, St. Louis, pp 33–70
Nakata K, Naitoh M, Izumi M, Inamoto K, Ariji E,
Nakamura H (2006) Effectiveness of dental computed
tomography in diagnostic imaging of periradicu-
lar lesion of each root of a multirooted tooth: a case
report. J Endod 32:583–587
Nance R, Tyndall D, Levin LG, Trope M (2000)
Identification of root canals in molars by tuned-­aperture
computed tomography. Int Endod J 33:392–396
Natkin E, Oswald RJ, Carnes LI (1984) The relationship
of lesion size to diagnosis, incidents and treatment of
919
periapical cysts and granulomas. Oral Surg Oral Med
Oral Pathol 57:82–94
Nawa H, Oberoi S, Vargervik K (2008) Taurodontism
and van der Woude syndrome. Is there an association?
Angle Orthod 78:832–837
Ne RF, Witherspoon DE, Gutmann JL (1999) Tooth
resorption. Quintessence Int 30:9–25
Neelakantan P, Subbarao C, Subbarao CV (2010)
Comparative evaluation of modified canal staining
and clearing technique, cone-beam computed tomog-
raphy, peripheral quantitative computed tomography,
spiral computed tomography, and plain and contrast
medium-enhanced digital radiography in studying
root canal morphology. J Endod 36:1547–1551
Neves FS, Freitas DQ, Campos PS, Ekestubbe A, Lofthag-­
Hansen S (2014) Evaluation of cone-beam computed
tomography in the diagnosis of vertical root fractures:
the influence of imaging modes and root canal materi-
als. J Endod 40:1530–1536
Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K
(2008) Outcome of primary root canal treatment: sys-
tematic review of the literature - part 2. Influence of
clinical factors. Int Endod J 41:6–31
Ng YL, Mann V, Gulabivala K (2010) Tooth survival fol-
lowing non-surgical root canal treatment: a systematic
review of the literature. Int Endod J 43:171–189
Nicopoulou-Karayianni K, Bragger U, Lang NP (1997)
Patterns of periodontal destruction associated with incom-
plete root fractures. Dentomaxillofac Radiol 26:321–326
Niemczyk SP (2010) Essentials of endodontic microsur-
gery. Dent Clin N Am 54:375–399
Nudera WJ (2015) Selective root retreatment: a novel
approach. J Endod 41:1382–1388
Nurbakhsh B, Friedman S, Kulkarni GV, Basrani B, Lam E
(2011) Resolution of maxillary sinus mucositis after end-
odontic treatment of maxillary teeth with apical periodon-
titis: a cone-beam computed tomography pilot study. J
Endod 37:1504–1511
Oehlers FA (1957) Dens invaginatus. I. Variations of the
invagination process and associated anterior crown
forms. Oral Surg Oral Med Oral Pathol 10:1204–1218
Ørstavik D (1996) Time-course and risk analyses of the
development and healing of chronic apical periodonti-
tis in man. Int Endod J 29:150–155
Ozen T, Kamburoğlu K, Cebeci AR, Yüksel SP, Paksoy
CS (2009) Interpretation of chemically created peri-
apical lesions using 2 different dental cone-beam com-
puterized tomography units, an intraoral digital sensor,
and conventional film. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 107:426–432
Ozer SY (2011) Detection of vertical root fractures by
using cone beam computed tomography with variable
voxel sizes in an in vitro model. J Endod 37:75–79
Pagella F, Matti E, De Bernardi F, Semino L, Cavanna C,
Marone P, Farina C, Castelnuovo P (2007) Paranasal sinus
fungus ball: diagnosis and management. Mycoses 50:
451–456
Palomo L, Palomo JM (2009) Cone beam CT for diagno-
sis and treatment planning in trauma cases. Dent Clin
N Am 53(717–27):vi–vii
920
Patel S (2009) New dimensions in endodontic imaging:
part 2. Cone beam computed tomography. Int Endod
J 42:463–475
Patel S, Dawood A (2007) The use of cone beam com-
puted tomography in the management of external cer-
vical resorption lesions. Int Endod J 40:730–737
Patel S, Dawood A, Ford TP, Whaites E (2007) The poten-
tial applications of cone beam computed tomography
in the management of endodontic problems. Int Endod
J 40:818–830
Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T
(2009a) Detection of periapical bone defects in human
jaws using cone beam computed tomography and
intraoral radiography. Int Endod J 42:507–515
Patel S, Kanagasingam S, Pitt Ford T (2009b) External
cervical resorption: a review. J Endod 35:616–625
Patel S, Dawood A, Wilson R, Horner K, Mannocci F
(2009c) The detection and management of root resorp-
tion lesions using intraoral radiography and cone beam
computed tomography – an in vivo investigation. Int
Endod J 42:831–838
Patel S, Kanagasingam S, Mannocci F (2010a) Cone
beam computed tomography (CBCT) in endodontics.
Dent Update 37:373–379
Patel S, Ricucci D, Durak C, Tay F (2010b) Internal root
resorption: a review. J Endod 36:1107–1121
Patel S, Wilson R, Dawood A, Mannocci F (2012a) The
detection of periapical pathosis using periapical radi-
ography and cone beam computed tomography – part
1: pre-operative status. Int Endod J 45:702–710
Patel S, Wilson R, Dawood A, Foschi Mannocci F (2012b)
The detection of periapical pathosis using digital peri-
apical radiography and cone beam computed tomog-
raphy – part 2: a 1-year post-treatment follow-up. Int
Endod J 45:711–723
Patel S, Brady E, Wilson R, Brown J, Mannocci F (2013)
The detection of vertical root fractures in root filled
teeth with periapical radiographs and CBCT scans. Int
Endod J 46:1140–1152
Patel S, Durack C, Abella F, Shemesh H, Roig M,
Lemberg K (2015) Cone beam computed tomography
in Endodontics – a review. Int Endod J 48:3–15
Peters CI, Peters OA (2012) Cone beam computed tomog-
raphy and other imaging techniques in the determina-
tion of periapical healing. Endod Topics 26:57–75
Pineda F (1973) Roentgenographic investigation of the
mesiobuccal root of the maxillary first molar. Oral
Surg Oral Med Oral Pathol 36:253–260
Pineda F, Kuttler Y (1972) Mesiodistal and buccolingual
roentgenographic investigation of 7,275 root canals.
Oral Surg Oral Med Oral Pathol 33:101–110
Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment
DP (2006) Accuracy of three-dimensional measure-
ments using cone-beam CT. Dentomaxillofac Radiol
35:410–416
Pope O, Sathorn C, Parashos P (2014) A comparative
investigation of cone-beam computed tomography and
periapical radiography in the diagnosis of a healthy
periapex. J Endod 40:360–365
Ramamurthy R, Scheetz JP, Clark SJ, Farman AG (2006)
Effects of imaging system and exposure on accurate
S.L. Doyle et al.
detection of the second mesio-buccal canal in maxil-
lary molar teeth. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 102:796–802
Reit C (1987) Decision strategies in endodontics: on the
design of a recall program. Endod Dent Traumatol
3:233–239
Rigolone M, Pasqualini D, Bianchi L, Berutti E, Bianchi
SD (2003) Vestibular surgical access to the palatine
root of the superior first molar: “low-dose cone-beam”
CT analysis of the pathway and its anatomic varia-
tions. J Endod 29:773–775
Rosen E, Taschieri S, Del Fabbro M, Beitlitum I, Tsesis
I (2015) The diagnostic efficacy of cone-beam com-
puted tomography in endodontics: a systematic review
and analysis by a hierarchical model of efficacy. J
Endod 41:1008–1014
Rosenberg P, Frisbie J, Lee J, Lee K, Frommer H, Kottal
S, Phelan J (2010) Evaluation of pathologists (histo-
pathology) and radiologists (cone beam computed
tomography) differentiating radicular cysts from gran-
ulomas. J Endod 36:423–428
Salehrabi R, Rotstein I (2004) Endodontic treatment out-
comes in a large patient population in the USA: an epi-
demiological study. J Endod 30:846–850
Sanders B, Brady FA, Johnson R (1979) Injuries. In:
Sanders B (ed) Pediatric oral and maxillofacila sur-
gery, 1st edn. CV Mosby, St. Louis, p 330
Scarfe WC, Czerniejewski VJ, Farman AG, Avant SL,
Molteni R (1999) In vivo accuracy and reliability
of color-coded image enhancements for the assess-
ment of periradicular lesion dimensions. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 88:
603–611
Scarfe WC, Levin MD, Gane D, Farman AG (2009) Use
of cone beam computed tomography in endodontics.
Int J Dent 2009:634567
Schwartz SF, Foster JK (1971) Roentgenographic inter-
pretation of experimentally produced bone lesions.
Oral Surg Oral Med Oral Pathol 32:606–612
Selden HS (1989) The endo-antral syndrome: an end-
odontic complication. J Am Dent Assoc 119(397–8):
401–402
Selden HS (1994) Diagnostic radiographic findings and
symptom free teeth. J Endod 20:100–102
Selden HS (1999) Endo-antral syndrome and various end-
odontic complications. J Endod 25:389–393
Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S
(2010) Outcome of endodontic surgery: a meta-­
analysis of the literature - part 1: comparison of tradi-
tional root-end surgery and endodontic microsurgery.
J Endod 36:1757–1765
Shanbhag S, Karnik P, Shirke P, Shanbhag V (2013)
Association between periapical lesions and maxillary
sinus mucosal thickening: a retrospective cone-beam
computed tomographic study. J Endod 39:853–857
Shemesh H, Cristescu RC, Wesselink PR, Wu M-K (2011)
The use of cone-beam computed tomography and dig-
ital periapical radiographs to diagnose root perfora-
tions. J Endod 37:513–516
Shoha RR, Dowson J, Richards AG (1974) Radiographic
interpretation of experimentally produced bone
22  Endodontic Applications of CBCT
lesions. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 38:294–303
Siew K, Lee A, Cheung G (2015) Treatment outcome
of repaired root perforation: a systematic review and
meta-analysis. J Endod 41:1795–1804
Silva EJ, Nejaim Y, Silva AV, Haiter-Neto F, Cohenca
N (2013) Evaluation of root canal configuration of
mandibular molars in a Brazilian population by using
cone-beam computed tomography: an in vivo study. J
Endod 39:849–852
Silva EJ, Nejaim Y, Silva A, Haiter-Neto F, Zaia AA,
Cohenca N (2014) Evaluation of root canal configu-
ration of maxillary molars in a Brazilian population
using cone-beam computed tomographic imaging: an
in vivo study. J Endod 40:173–176
Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry
M, Patel A (2006) Differential diagnosis of large peri-
apical lesions using cone-beam computed tomography
measurements and biopsy. J Endod 32:833–837
Soğur E, Baksı BG, Gröndahl H-G, Lomcali G, Sen
BH (2009) Detectability of chemically induced peri-
apical lesions by limited cone beam tomography,
intra-oral digital and conventional film radiography.
Dentomaxillofac Radiol 40:458–464
Stavropoulos A, Wenzel A (2007) Accuracy of cone beam
dental CT, intraoral digital and conventional film radi-
ography for the detection of periapical lesions. An
ex vivo study in pig jaws. Clin Oral Investig 11:101–106
Strindberg LZ (1956) The dependence of the results of
pulp therapy on certain factors. An analytic study
based on radiographic and clinical follow-up exami-
nations. Acta Odontol Scand 14(Suppl 21):1–175
Stropko JJ (1999) Canal morphology of maxillary molars:
clinical observations of canal configurations. J Endod
25:446–450
Talwar S, Utneja S, Nawal RR, Kaushik A, Srivastava
D, Oberoy SS (2016) Role of cone-beam computed
tomography in diagnosis of vertical root fractures: a
systematic review and meta-analysis. J Endod 42:12–24
Tamse A (2006) Vertical root fractures in endodontically
treated teeth: diagnostic signs and clinical manage-
ment. Endod Top 13:84–94
Tamse A, Fuss Z, Lustig J, Kaplavi J (1999a) An evalu-
ation of endodontically treated vertically fractured
teeth. J Endod 25:506–508
Tamse A, Fuss Z, Lustig J, Ganor Y, Kaffe I (1999b)
Radiographic features of vertically fractured, end-
odontically treated maxillary premolars. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 88:348–352
Tamse A, Kaffe I, Lustig J, Ganor J, Fuss Z (2006)
Radiographic features of vertically fractured end-
odontically treated mesial roots of mandibular molars.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
101:797–802
Tanomaru-FIlho M, Jorge ÉG, Guerreiro-Tanomaru JM,
Reis JM, Spin-Neto R, Gonçalves M (2015) Two- and
tridimensional analysis of periapical repair after end-
odontic surgery. Clin Oral Investig 19:17–25
Testori T, Badino M, Castagnola M (1993) Vertical root
fractures in endodontically treated teeth: a clinical sur-
vey of 36 cases. J Endod 19:87–91
921
Testori T, Capelli M, Milani S, Weinstein RL (1999)
Success and failure in periradicular surgery: a longitu-
dinal retrospective analysis. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 87:493–498
Todd R (2014a) Cone beam computed tomography
updated technology for endodontic diagnosis. Dent
Clin N Am 58:523–543
Todd R (2014b) Dental imaging – 2D to 3D: a historic,
current, and future view of projection radiography.
Endod Topics 31:36–52
Torabinejad M, Landaez M, Milan M et al (2015) Tooth
retention through endodontic microsurgery or tooth
replacement using single implants: a systematic
review of treatment outcomes. J Endod 41:1–10
Tronstad L (1988) Root resorption - etiology, terminology
and clinical manifestations. Endod Dent Traumatol
4:241–252
Tsai P, Torabinejad M, Rice D, Azevedo B (2012)
Accuracy of cone-beam computed tomography and
periapical radiography in detecting small periapical
lesions. J Endod 38:965–970
Tsesis I, Rosen E, Tamse A, Taschieri S, Kfir A (2010)
Diagnosis of vertical root fractures in endodontically
treated teeth based on clinical and radiographic indi-
ces: a systematic review. J Endod 36:1455–1458
Tsukiboshi M (2006) Optimal use of photography, radi-
ography and micro computed tomography scanning in
the management of traumatized teeth. Endod Topics
14:4–19
Tsurumachi T, Honda K (2007) A new cone beam com-
puterized tomography system for use in endodontic
surgery. Int Endod J 40:224–232
Tu M-G, Tsai C-C, Jou M-J et al (2007) Prevalence of
three-rooted mandibular first molars among Taiwanese
individuals. J Endod 33:1163–1166
Tu MG, Huang HL, Hsue SS, Hsu JT, Chen SY, Jou MJ,
Tsai CC (2009) Detection of permanent three-rooted
mandibular first molars by cone-beam computed
tomography imaging in Taiwanese individuals. J
Endod 35:503–507
Tyndall DA, Kohltfarber H (2012) Application of cone
beam volumetric tomography in endodontics. Aust
Dent J 57(Suppl 1):72–81
Tyndall DA, Rathore S (2008) Cone-beam CT diagnostic
applications: caries, periodontal bone assessment, and
endodontic applications. Dent Clin N Am 52:825–841
Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C,
Scarfe WC (2011) Position statement of the American
Academy of oral and maxillofacial radiology on
selection criteria for the use of radiology in dental
implantology with emphasis on cone beam computed
tomography. Oral Surg Oral Med Oral Pathol Oral
Radiol 113:817–826
van der Borden WG, Wang X, Wu MK, Shemesh H
(2013) Area and 3-dimensional volumetric changes of
periapical lesions after root canal treatments. J Endod
39:1245–1249
Venskutonis T, Plotino G, Juodzbalys G, Mickevičienė
L (2014) The importance of cone-beam computed
tomography in the management of endodontic prob-
lems: a review of the literature. J Endod 40:1895–1901
922
Venskutonis T, Plotino G, Tocci L, Gambarini G,
Maminskas J, Juodzbalys G (2015) Periapical and end-
odontic status scale based on periapical bone lesions
and endodontic treatment quality evaluation using cone-
beam computed tomography. J Endod 41:190–196
Vertucci FJ (1984) Root canal anatomy of human per-
manent teeth. Oral Surg Oral Med Oral Pathol 58:
589–599
Vizzotto MB, Silveira PF, Arus NA, Montagner F, Gomes
BP, da Silveira HE (2013) CBCT for the assessment of
second mesiobuccal (MB2) canals in maxillary molar
teeth: effect of voxel size and presence of root filling.
Int Endod J 46:870–876
Vogiatzi T, Kloukos D, Scarfe WC, Bornstein MM (2014)
Incidence of anatomical variations and disease of the
maxillary sinuses as identified by cone beam com-
puted tomography: a systematic review. Int J Oral
Maxillofac Implants 29:1301–1314
von Arx T, Gerber C, Hardt N (2001) Periradicular sur-
gery of molars: a prospective clinical study with a one-­
year follow-up. Int Endod J 34:520–525
Walton RE (1973) Endodontic radiographic technics.
Dent Radiogr Photogr 46:51–59
Walton RE (2008) Diagnostic imaging. A endodontic
radiography. In: Ingle JI, Bakland LK, Baumgartner
JC (eds) Ingles’ endodontics, 6th edn. BC Decker Inc,
Hamilton, ON, p 554
Walton RE, Fouad AF (2015) Endodontic radiogra-
phy. In: Torabinejad M, Walton RE, Fouad AF (eds)
Endodontics: principles and practice, 5th edn. Elsevier
Saunders, St. Louis, pp 198–217
S.L. Doyle et al.
Walton RE, Michelich RJ, Smith GN (1984) The his-
topathogenesis of vertical root fractures. J Endod
10:48–56
Wang P, Yan XB, Lui DG, Zhang WL, Zhang Y, Ma XC
(2011) Detection of dental root fractures by using
cone-beam computed tomography. Dentomaxillofacial
Rad 40:290–298
Weine FS, Healey HJ, Gerstein H, Evanson L (1969)
Canal configuration in the mesiobuccal root of the
maxillary first molar and its endodontic significance.
Oral Surg Oral Med Oral Pathol 28:419–425
Wolcott J, Ishley D, Kennedy W, Johnson S, Minnich
S, Meyers J (2005) A 5-year clinical investigation
of second mesiobuccal canals in endodontically
treated and retreated maxillary molars. J Endod 31:
262–264
Wu M-K, Shemesh H, Wesselink PR (2009) Limitations
of previously published systematic reviews evaluat-
ing the outcome of endodontic treatment. Int Endod
J 42:656–666
Yonetsu K, Yuasa K, Kanda S (1997) Idiopathic osteoscle-
rosis of the jaws: panoramic radiographic and com-
puted tomographic findings. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 83:517–521
Yoo JY, Pi SH, Kim YS, Jeong SN, You HK (2011)
Healing pattern of the mucous membrane after tooth
extraction in the maxillary sinus. J Periodontal Implant
Sci 41:23–29
Young GR (2007) Contemporary management of lateral
root perforation diagnosed with the aid of dental com-
puted tomography. Aust Endod J 33:112–118