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CBCT in Endodntics - Doyle 2017 PDF
CBCT in Endodntics - Doyle 2017 PDF
CBCT
22
Scott L. Doyle, Bruno Azevedo, Martin D. Levin,
David Gane, Allan G. Farman, and William C. Scarfe
plane, with buccolingual and buccopalatal observers when determining the outcome of
features often absent. Multiple periapical treatment (Goldman et al. 1972, 1974).
images from slightly varying angles are often
exposed to assist in visualization (Brynolf
1970; Walton 1973; Martinez-Lozano et al. 22.2.2 Advantages of CBCT
1999; Gröndahl and Huumonen 2004). in Endodontics
• Detection of Periapical Pathosis. An apical
lesion often requires extensive decalcification CBCT imaging, especially limited field of view
of the cortical plate to be detected radiographi- (FOV), high resolution modalities, overcome
cally on conventional 2D images (Bender and many of the limitations of conventional imag-
Seltzer 1961a, b; Bender 1982), with cancel- ing in contemporary endodontic practice by
lous lesions being more difficult to detect producing undistorted and geometrically accu-
(Schwartz and Foster 1971; Folk et al. 2005) rate three-dimensional images. This influences
and often underestimated in size (Shoha et al. how clinicians diagnose, treatment plan, manage
1974; Lee and Messer 1986; Barbat and Messer (Ee et al. 2014), and assess treatment outcomes
1998; Scarfe et al. 1999; Marmary et al. 1999). (Figs. 22.1, 22.2, 22.3, 22.4, and 22.5).
• Assessment of Periradicular Tissue Healing. Specific advantages of CBCT for endodontics
Periapical radiography has historically been include:
used to monitor changes in the periradicular tis-
sues in order to assess outcomes following end- • Images are interactive and interrelational in
odontic treatment. Favorable outcomes depend three orthogonal planes (axial, sagittal, and
on healing of the supporting bone. Repair of coronal).
periradicular tissues consists of a complex • The ability to reorient data such that coronal and
regeneration involving bone, periodontal liga- sagittal images are parallel with, and axial images
ment, and cementum (Huumonen and Orstavik perpendicular, to the long axis of the root.
2002). Accurate determination of the true status • Multi-planar reformation (MPR) images can be
of periapical tissues is limited with conventional used to highlight specific anatomic regions in
radiography (Peters and Peters 2012). Healing relation to endodontic investigation (Figs. 22.1
of periradicular lesions is assessed by interpre- and 22.2).
tation of periodic checkup radiographs but there • Enhancements including zoom or magnifica-
is a great degree of variability within and among tion, window/level adjustments, and annota-
a b
Fig. 22.1 The periapical image of the maxillary right cropped sagittal thin section CBCT image (b) demon-
second molar (a) in an asymptomatic patient is unremark- strates a furcal area of low density and associated perira-
able and shows lack of coverage of this tooth with marked dicular periodontitis. Subsequent clinical investigation
superimposition of the distal root of the first molar over found the pulp in this tooth to be necrotic
the mesial root of the second molar. The corresponding
874 S.L. Doyle et al.
a b
c d e
Fig. 22.2 A periapical image (a) of the maxillary right sity centered on the palatal root of the maxillary first
posterior region in a patient presenting with discomfort molar, and extending to each tooth either side. Note the
extending from the nose to the ear, local buccal swelling internal resorptive defect at the junction of the apical and
and induration. All teeth tested vital except the maxillary middle thirds of the palatal root of the maxillary first
right first molar. Periapical image (a) shows an area of low molar, not visible on the periapical image. Biopsy con-
density at the apices of the first and second molars. 10 mm firmed the lesion to be a periapical granuloma with
curved planar (b), axial (c), sagittal (d), and cross- abscess formation at the time of root canal treatment and
sectional (e) CBCT images demonstrate a much larger surgery
(21.4 mm maximum length) unilocular area of low den-
a b c
Fig. 22.3 Parasagittal (a), axial (b), and correlated mul- digital panoramic image (d) revealed similar bony pat-
tiple cross-sectional (c) images of a 52-year-old Caucasian terns in the left posterior maxilla and mandible and con-
female presenting for assessment of multiple periapical firmed the working diagnosis of florid cemento-osseous
areas associated with the mandibular right first and second dysplasia and concomitant hypercementosis on the right
molars. There are areas of mixed central opacity and mandibular first molar. Management of this patient com-
peripheral radiolucency associated with the apices of the prised CBCT radiographic checkup at 6 months to assess
teeth however no expansion, tooth resorption or displace- the progression of the hyperdensities
ment is evident. All teeth in this quadrant tested vital. A
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 22.2.3 Challenges of CBCT for Use
images. in Endodontics
• Interactive, on-screen measurements provide
dimensions free from distortion and magnifi- 22.2.3.1 Technical
cation (Fig. 22.2). • Spatial resolution. The spatial resolution of
• Assessment of a quadrant or sextant of teeth CBCT images (0.4–0.075 mm voxel size, equiv-
and supporting bone in one image, which may alent to 1.25–6.6 line pairs per mm−1(lp.mm−1))
reduce radiation exposure compared to mul- is inferior to film-based (approx. 20 lp.mm−1) or
tiple intraoral images. digital (ranging from 8–23 lp.mm−1) intraoral
• Extraoral imaging in trauma cases where radiography. The optimal resolution for CBCT
placement of an intraoral detector would be images in endodontics is task specific, invariably
problematic. involving imaging of inherently small structures.
• Quantification of volumetric data such as Liedke et al. (2009) recommend a minimal
amount of bony change and healing. voxel resolution of 0.3 mm (1.6 lp.mm−1) for the
876 S.L. Doyle et al.
a b c
Fig. 22.5 Thick section (10 mm) sagittal (a), thin section and PDL space. No previous imaging was available, how-
sagittal (b), and axial image (c) showing a unilocular, ever the patient did report that endodontic therapy on this
well-defined, tear-shaped relative hyperdensity associated tooth was performed approximately 2–3 years previously.
with the distal aspect of a left mandibular root canal The homogeneous nature and confluence with adjacent
treated first molar. The patient was asymptomatic and intramedullary bone is most consistent with sclerotic
referred for an opinion with a concern for a possible healing
cementoblastoma, suggested by the loss of lamina dura
detection of external root resorption. Bauman the region of interest susceptible to beam
et al. (2011) investigated the effect of varying hardening (e.g., metallic restorations, dental
isotropic voxel dimensions on the detection of implants). Cropping the FOV of the scan to
secondary canals in the mesiobuccal root of the the root portion of the tooth may also negate
maxillary first permanent molar. They showed the effect of metallic artifacts. New algorithms
that observer inter-rater reliability and detection and flat-panel detectors promise to reduce
of mesiobuccal canals improves with increasing scatter and beam hardening artifacts in the
resolution from 60.1% (0.4 mm/1.25 lp.mm−1) future (Dang et al. 2015).
to 93.3% (0.125 mm/4 lp.mm−1). The diagnosis • Contrast resolution. CBCT images also lack the
of subtler conditions (e.g., early stages of apical ability to record subtle changes in attenuation
periodontitis) involving the periodontal ligament of soft tissues. This feature would be of poten-
(PDL) space, which has an average dimension tial importance in distinguishing the nature of
of 0.2 mm, may demand resolution at or below periapical (e.g., abscess vs. cyst vs. granuloma)
0.2 mm voxel size (2.5 lp.mm−1) (Scarfe et al. or sinus soft tissue contents. Current CBCT
2009). imaging is primarily limited to the assessment
• The presence of artifacts. CBCT images, like of the dentition and osseous structures.
those from other imaging modalities, are sus-
ceptible to artifacts that affect fidelity (see 22.2.3.2 Interpretation
Chap. 2). The presence of radiopaque metal Interpretation of CBCT images requires consid-
objects and root canal filling materials in the erable experience and training. The clinician is
field of view (FOV) can lead to severe beam responsible for the evaluation of the entire image
hardening and streaking artifacts. In clinical volume, not only the tooth or pathosis in the
endodontic practice, CBCT scanners with a volume of interest. If a clinician has a concern
limited FOV may provide clearer images as regarding image interpretation, the case should be
they can avoid scanning structures outside referred to an oral and maxillofacial radiologist.
22 Endodontic Applications of CBCT 877
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 S.L. Doyle et al.
terization of disruptions in the PDL space, preoperative CBCT imaging provides additional
small resorptive defects and localization diagnostic and treatment planning information
of calcified canals; an optimal resolu- (Figs. 22.6 and 22.7).
tion of approximately 0.125 μm or less is Mota de Almeida et al. (2014a) compared
preferred. therapy plan changes before and after CBCT
–– Exposure settings. The lowest mA setting imaging on 53 patients (81 teeth) referred from
and the shortest exposure time in conjunc- specialty endodontic practices. The primary
tion with a pulsed exposure mode of acqui- reasons for referral were differentiating patho-
sition are recommended. sis from normal anatomy (47%) and presurgi-
–– Dose. Depending on the equipment used, cal assessment (25%). Treatment plan changes
CBCT exposure may expose a patient to were made in 53% of patients after CBCT
comparable or slightly higher radiation imaging. In a related study using the same
doses. This is especially important when database, the authors found that use of CBCT
considering 3D imaging for children (up to imaging led to diagnostic changes in 41% of
18 years old) and pregnant patients. patients and 35% of teeth (Mota de Almeida
–– Task-specific imaging. Depending on the et al. 2014b).
diagnostic objective of the imaging study, Ee et al. (2014) compared the relative diag-
selecting a larger voxel size, 180° instead nostic value of preoperative periapical images
of 360° rotation, or lower kVp and/or mA alone to CBCT image findings on 30 patients in a
can reduce radiation dose to the patient private practice setting. They used a preliminary
(e.g., temporal imaging of the same area to diagnosis and treatment plan based on clinical
assess gross changes). Exposure parame- diagnosis and the interpretation of both imag-
ters can be reduced when acquiring a series ing modalities as the diagnostic “gold” standard.
of radiographs to monitor bony changes They found sensitivity to be 36.6–40% when
during checkup, as opposed to endodontic using periapical images alone and 76.6–83.3%
assessments which generally require high when CBCT imaging was used. The examiners
resolution, and hence increased exposure altered their treatment plan in 62.2% of the cases
parameters. after viewing the CBCT scan and concluded that
availability of a preoperative CBCT can directly
influence a clinician’s treatment plan.
22.3.2 Clinical Efficacy: Effect on It is important to emphasize that evaluation of
Diagnosis and Treatment the patient’s chief complaint, history, clinical and
Planning radiographic findings are all considered essential
to the formulation of a diagnosis and treatment
The diagnostic efficacy hierarchical model is plan.
used to appraise the efficacy levels for an imag-
ing modality (Fryback and Thornbury 1991).
The model presents six levels of imaging effi- 22.3.3 Preoperative Assessment
cacy: Level 1—Technical, Level 2—Diagnostic
accuracy, Level 3—Diagnostic thinking, Level There are numerous situations in the assessment
4—Therapeutic, Level 5—Patient outcome, and phase of endodontics where CBCT imaging can
Level 6—Societal efficacy. Systematic reviews assist in the diagnosis and subsequent treatment
(European Commission SEDENTEXCT 2012; planning of endodontic disease and in the evalu-
Rosen et al. 2015; Kruse et al. 2015) on the diag- ation of dental features that may affect therapy.
nostic efficacy of CBCT imaging in endodon- Teeth with anatomical variations and complex
tics report that most studies have a low level of morphology may be indications for 3D imaging.
efficacy (levels 1, 2, or 3), with none at level CBCT is significantly better in terms of sensitiv-
6. However, recent Level 4 studies suggest that ity, positive or negative predictive values, and
22 Endodontic Applications of CBCT 879
a b
c d
Fig. 22.6 Periapical image (a) of symptomatic maxillary maxillary sinus floor, secondary soft tissue involvement
left first molar showing a periapical radiolucency suggest- and a mid-root palatal resorptive defect. While nonsurgi-
ing an untreated MB2 canal. Axial (b) CBCT image con- cal retreatment may have been recommended based on the
firms the presence of an untreated MB2. Parasagittal (c) periapical image, CBCT imaging substantially changes
and cross-sectional (d) CBCT images demonstrate an api- the prognosis and treatment recommendation
cal area of low density, cortical bone resorption of the
diagnostic accuracy than digital or conventional A thorough understanding of specific root canal
radiographs (Peters and Peters 2012) with the anatomy is essential prior to initiating treatment.
exception of the assessment of vertical root frac- Multiple in vitro (ex vivo) studies have vali-
tures of root-treated teeth (Talwar et al. 2016). dated the use of CBCT in identifying root canal
systems compared to multiple intraoral images
22.3.3.1 Tooth Root Anatomy (Matherne et al. 2008; Neelakantan et al. 2010).
Anatomical variations exist with each tooth These studies report high detection rates com-
and root type. The success of endodontic treat- pared to histologic sections (Michetti et al. 2010)
ment depends on the identification of all root and similar detection rates to staining and clear-
canal systems so that they can be accessed, ing techniques on extracted teeth (Neelakantan
cleaned, shaped, and obturated (Vertucci 1984). et al. 2010) (Fig. 22.8).
880 S.L. Doyle et al.
a b
c d
Fig. 22.7 Periapical image (a) of patient with vague pain demonstrates extensive calcification of the unrestored first
in the right mandibular area for several years with incon- molar. Axial (b), mesial (c), and distal (d) coronal CBCT
clusive clinical and microscopic findings. This image images show a significant mesial-distal fracture
b c d e f
Fig. 22.8 Cropped panoramic image (a) of a patient who right (c) and left (d) central incisors, left lateral incisor (e)
presented with pain/swelling in the mandibular anterior and left canine (f) illustrate areas of low density with
region after multiple root canal treatments of the mandib- asymmetry of the previous filling material and evidence of
ular teeth. Coronal CBCT images of the right canine (b), untreated canal space
(Stropko 1999). Clinicians should be aware that Blattner et al. (2010) assessed extracted max-
untreated MB2 canals likely have a negative illary molars for the prevalence of MB2 canals.
impact on the outcome of endodontic treatment They found an 80% correlation between the
(Wolcott et al. 2005; Huumonen et al. 2006). results using CBCT and tooth sectioning. Viz-
Barato Filho et al. (2009) investigated the inter- zotto et al. (2013) showed CBCT to have higher
nal morphology of extracted maxillary first molars mean values of specificity and sensitivity when
using ex vivo sections, CBCT and clinical treatment compared to intraoral radiographs in the detec-
using an operating microscope. Results showed that tion of the MB2 canal.
when an additional canal was present, it was located Bauman et al. (2011) investigated the effect of
in the MB root 92.85–95.63% of the time. Addi- increasing voxel resolution on the detection rate
tional canals were also located in the DB and pala- of multiple observers of the MB2 on 24 maxillary
tal roots, though much less frequently. The authors first molars by CBCT. Compared to the overall
concluded that CBCT provides a good method for prevalence of MB2 (92%), CBCT detection rates
the initial evaluation of maxillary first molar inter- increased from 60 to 93.3% with increasing reso-
nal morphology. The location and identification of lution, suggesting that if CBCT is to be used then
the root canals were facilitated by the combined use resolutions in the order of 0.12 mm or less are
of an operating microscope and CBCT. 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 883
a b c
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
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 885
• Type II: The deeper and enamel-lined invagi- with Down syndrome. CBCT provides impor-
nation extends below the CEJ but remains tant information characterizing this anomaly,
within the root, ending in a blind sac. The pulp potentially important in endodontic treatment
shows no direct communication with the peri- considerations (Nawa et al. 2008; Borges et al.
odontal ligament (Fig. 22.12). 2014).
• Type III: The severe invagination extends
through the root to form an additional apical Dilaceration
(IIIA) or lateral (IIIB) foramen (Fig. 22.13). Dilaceration is a root anomaly with an abrupt
There is usually no direct communication with change in direction of the long axis of the root
the pulp. The invagination may be completely of the tooth in relation to the crown. The defin-
lined by enamel but cementum may also be ing criteria vary from a deviation of 20° in the
present. In Type III variations, any infec- apical part of the root to a 90° or greater angle.
tion within the invagination can lead to an It can occur as a result of trauma, or occur spon-
inflammatory response within the periodon- taneously and has been associated with some
tal tissues giving rise to a “peri-invagination developmental syndromes. It can occur in both
periodontitis.” deciduous and permanent teeth, more commonly
in posterior teeth and in the maxilla. The pres-
A recent retrospective study using CBCT ence of a dilaceration can severely complicate
found type I to be the most commonly observed endodontic treatment (Jafarzadeh and Abbott
(65.9%), followed by type II (29.5%) and type III 2007).
(4.6%) (Capar et al. 2015).
Teeth affected by dens invaginatus are prone Gemination/Fusion
to developing caries within the invagination that Both gemination and fusion are developmen-
may result in pulp necrosis and subsequent peri- tal disorders of individual teeth associated with
radicular periodontitis (Figs. 22.13 and 22.14). abnormalities in the differentiation of dental lam-
Successful endodontic treatment depends on ina. Gemination occurs when two teeth develop
characterization of the anatomical variations of from one enamel organ producing a single root
the anomaly including the irregular shape of the structure with two partial or completely separated
root canal system and appreciation of the degree crowns. Fusion is a union of two teeth, normally
of involvement of the pulp and/or invagination with separated enamel organs leading to the for-
(John 2008). mation of a joined tooth with the confluence of
dentin. The clinician benefits from a knowledge
Taurodontism of the root canal system provided by CBCT for
The characteristic features of teeth with this con- treatment of both conditions.
dition include an enlarged pulp chamber, apical
displacement of the pulpal floor and no constric- 22.3.3.3 Dental Periapical Pathosis
tion at the level of the CEJ (Jafarzadeh et al. Apical periodontitis (AP) is generally considered
2008). The prevalence of taurodontism has been to be a sequelae of pulp necrosis and subsequent
reported to range from 0.5 to 46.4% depending microbial infection and results in local inflam-
on the population studied, with most authors mation, resorption of hard tissues, destruction of
reporting from 5 to 10%. The trait has been other periapical tissues, and eventual formation
reported to be inherited as autosomal recessive of various histopathological entities such as gran-
and associated with numerous syndromes and ulomas, cysts, or abscesses (Bhaskar 1968; Nair
conditions including cleft lip and palate (Laa- 2004). Because radiographic distinction between
tikainen and Ranta 1996), tricho-dento-osseous these entities is difficult, the bony destruction
syndrome, Klinefelter’s, Williams, McCune- observed radiographically associated with AP is
Albright syndromes, and probably most often commonly referred to as a periapical lesion.
886 S.L. Doyle et al.
a b c
Fig. 22.15 Periapical image (a) of patient with pain in (c) CBCT images of the second molar indicate areas of
the maxillary right quadrant, initially referred for retreat- low density associated with all root apices and concomi-
ment of the first molar. Parasagittal (b) and cross-sectional tant sinus mucosal thickening
a b c
Fig. 22.16 Periapical radiograph of the maxillary left odontitis has caused displacement of the periosteum but
second molar (a) shows an area of low density surround- does not penetrate the antral floor. Three months after
ing the mesial root with unfilled canal space. A parasagit- retreatment, CBCT imaging (c) demonstrates complete
tal CBCT image (b) shows a chronic periradicular apical resolution
osteoperiostitis, or “halo lesion,” where the apical peri-
to resolve following nonsurgical root canal treat- to help confirm the absence of an odontogenic
ment (Natkin et al. 1984; Nair 2003; Nair et al. etiology when managing nonodontogenic causes
1993). Numerous investigators have suggested of pain (Patel et al. 2015). Examples may include
that specific radiographic features can be used patients with sinusitis or neuropathic pain-related
to differentiate between cysts and granulomas. symptoms.
These include:
Residual (Persistent) Periapical Pathosis
• Cysts may be associated with a well-defined Most apical lesions treated by nonsurgical root
hypodensity that may slowly enlarge and ulti- canal therapy heal with hard tissue regenera-
mately cause expansion of the cortical plates. tion, resulting in elimination or reduction of
• The peripheral border of radicular cysts may the periapical radiolucency. However, in a pro-
be hyperostotic (sclerotic or corticated), portion of cases, asymptomatic radiolucencies
whereas the border of an apical abscess may persist after root canal treatment. These may
be diffuse and irregular. be due to persistent intraradicular infection,
extraradicular infection (principally actino-
However, differentiation between these enti- mycosis), extruded root canal filling or other
ties based on these and other features on CBCT exogenous materials causing a foreign body
imaging presentation have proven unreliable reaction, the accumulation of endogenous cho-
(Simon et al. 2006; Rosenberg et al. 2010; Guo lesterol crystals that irritate the periapical tis-
et al. 2013). Surgical biopsy and histopathologi- sue, true cystic lesions, and scar tissue healing
cal examination remains the current standard for of the lesion (Nair 2006). Radiographically, a
definitive diagnosis. scar may appear as incomplete bone fill with
The AAE and AAOMR (2015) state: a radiopaque periphery and an internal radio-
Limited FOV CBCT should be considered the
lucency. Scar tissue is most commonly found
imaging modality of choice for diagnosis in following apical surgery where there is a per-
patients who present with contradictory or nonspe- foration of both the buccal and lingual or
cific clinical signs and symptoms associated with palatal cortex. While most surgical sites heal
untreated or previously endodontically treated
teeth.
successfully within 12 months (Maddalone and
Gagliani 2003), some require longer periods
When patients present with poorly localized of time for complete resolution of the radiolu-
symptoms or suspected pathosis with limited cency (von Arx et al. 2001; Testori et al. 1999).
radiographic findings using conventional imag- CBCT may be considered for healing assess-
ing, CBCT may reveal the presence of previously ment following apical surgery (Tanomaru-Filho
undetected disease. CBCT may also be indicated et al. 2015) (Figs. 22.17 and 22.18).
888 S.L. Doyle et al.
a b c d
Fig. 22.17 Cross-sectional (a) and parasagittal (b) and parasagittal (d) CBCT images 12 months after root
CBCT images of a patient with a large well-defined resid- end resection and root end filling shows healing. The
ual apical area of low density after root canal treatment of biopsy revealed a periapical cyst. The adjacent teeth
the mandibular right central incisor. Cross-sectional (c) remain responsive to vitality testing
a b c
d e f
Fig. 22.18 Initial intraoral periapical image (a) of a patient CBCT volumetric (d), cross-sectional (e), and axial (f)
presenting with localized right mandibular swelling and fis- CBCT images taken at the time of the second presentation
tula tract. The image shows a first premolar acting as a show complete loss of buccal cortical plate and floating
bridge abutment with a large diffuse hypodensity (shown hyperdense, presumably extruded material. In the absence
with gutta percha). A periapical image of the tooth with of a fracture, surgical curettage, apicoectomy, retrograde
orthograde retreatment 6 weeks later (b). The patient pre- endodontic treatment and guided tissue regeneration was
sented 4 months later with similar signs and symptoms with planned based on this second imaging presentation
no apical resolution demonstrable on periapical images (c).
22 Endodontic Applications of CBCT 889
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
890 S.L. Doyle et al.
a b c
Fig. 22.20 Periapical (a) and cross-sectional CBCT due to a playground accident. The tooth was repositioned
image of an adolescent showing a middle third horizontal and splinted with follow-up periapical image (c) showing
root fracture of the left maxillary central incisor sustained excellent approximation of the segments
a b c d
Fig. 22.21 Periapical image (a) of an adolescent who tion with displacement of the crown lingually and the root
suffered from a traumatic blow to the anterior dentition. A facially. There is a concomitant alveolar fracture.
discontinuity of the interradicular bone between the max- Compared to the findings of the periapical image (a),
illary central incisors and slight widening of the PDL CBCT provides more information regarding the tooth dis-
space is noted. Thin cross-sectional (b), sagittal (c), and placement and associated alveolar fracture, which can
axial (d) CBCT images show antero-medial lateral luxa- lead to better repositioning of the traumatized teeth
passes directly through the fracture (Patel et al. and Rathore 2008; Patel 2009; Bornstein et al.
2015). Since root fractures often have an oblique 2009; Iikubo et al. 2009; May et al. 2013).
component in the sagittal plane (Andreasen Clinical outcomes depend on the exact loca-
et al. 2007), multiple radiographs from vary- tion of the fracture, extent of displacement, and
ing angles are recommended to maximize the potential communication of the fracture to the
likelihood of detection (Flores et al. 2007; Inter- oral cavity.
national Association of Dental Traumatology The AAE and AAOMR (2015) state:
2012). Limited FOV CBCT should be considered the
Numerous authors have illustrated the use- imaging modality of choice for diagnosis and
fulness of CBCT in the diagnosis (Figs. 22.16, management of limited dento-alveolar trauma, root
22.17, and 22.18) and management of dento- fractures, luxation, and/or displacement of teeth
and localized alveolar fractures, in the absence of
alveolar trauma, including root fractures (Tsuki- other maxillofacial or soft tissue injury that may
boshi 2006; Cohenca et al. 2007a; Tyndall require other advanced imaging modalities.
22 Endodontic Applications of CBCT 891
22.3.3.6 Root Resorption ible (Tronstad 1988). This generally has little
Root resorption is defined by the American Asso- clinical significance.
ciation of Endodontists (2012) as: • Inflammatory (infection-related). This is a
A condition associated with either a physiologic common complication following traumatic
or pathologic process resulting in a loss of dentin, luxation and avulsion injuries (Andreasen and
cementum, and/or bone. Vestergaard Pedersen 1985; Andreasen et al.
1995). Early detection is critical, as the pro-
It may result from traumatic luxation injuries,
cess can have a rapid onset and aggressive pro-
orthodontic tooth movement, or chronic infections
gression. External inflammatory resorption is
of the pulp and/or periodontal structures (Ne et al.
dependent on the presence of infected necrotic
1999). Since root resorption is usually asymp-
pulp tissue within the root canal space; there-
tomatic, radiographic examination is critical to
fore, it is responsive to endodontic treatment
determine the presence, extent, and location of the
(Andreasen 1985). Radiographically, the
defect. Based on the location in relation to the root
resorptive defect on the root surface has irreg-
surface, root resorption can be classified as exter-
ular borders and the surrounding bone may
nal or internal (Gartner et al. 1976; Tronstad 1988).
have radiolucent areas.
CBCT is reported to be superior to periapical
• Replacement (ankylosis-related). Replacement
radiography in the detection and localization of
resorption (ankylosis) occurs as a complica-
external and internal resorptive defects (da Sil-
tion following trauma to the PDL, especially
veira et al. 2007; Estrela et al. 2009; Patel et al.
in luxation injuries such as avulsion. The root
2009c; Bernardes et al. 2012; Kamburoğlu et al.
surface is resorbed and replaced with bone.
2011; D’Addazio et al. 2011; Durack et al. 2011).
Radiographically, the PDL space is absent and
Others have presented selected cases illustrat-
has a characteristic “moth-eaten” appearance
ing the utility of CBCT in the detection of small
(Tronstad 1988) (Figs. 22.22 and 22.23).
lesions, localizing and differentiating the resorp-
• External Cervical Resorption. External cervi-
tion from other conditions, classification of the
cal resorption (Bakland and Andreasen 2004),
lesion, determining prognosis and directing
also referred to as invasive cervical resorption
treatment (Cotton et al. 2007; Patel and Dawood
(Heithersay 1999a), is a pathologic condition
2007; Maini et al. 2008; Cohenca et al. 2007b;
occurring immediately below the epithelial
Patel et al. 2009c; Hahn et al. 2009). The accu-
attachment of the tooth in the cervical region.
racy of CBCT in the detection of surface defects,
The pulp is not involved in the etiology and
while higher than conventional imaging modali-
often occurs in a tooth with a vital pulp (Patel
ties, is not perfect (Hahn et al. 2009) and may
et al. 2009b). Predisposing factors include
improve with increasing voxel resolution.
a history of orthodontic treatment, dental
The AAE and AAOMR (2015) state:
trauma, intracoronal bleaching, prior surgical
Limited FOV CBCT is the imaging modality of procedures, and periodontal therapy. Many
choice in the localization and differentiation of exter-
nal and internal resorptive defects and the determina- teeth have multiple associations. However,
tion of appropriate treatment and prognosis. cervical resorption is often idiopathic
(Heithersay 1999a, b, 2004). Clinical signs
External Root Resorption (ERR) are often absent in the early stages. However,
ERR is a process that initiates in the periodon- the appearance of a pinkish color in the tooth
tium and affects the external surface of the root crown is highly suggestive of late stage exter-
(Andreasen 1985). Specific types include: nal resorption as the highly vascular resorptive
tissue becomes visible through thin residual
• Surface (repair-related). Transient process tooth structure. External cervical resorption is
involving small areas of the root surface fol- commonly misdiagnosed and confused with
lowing luxation and avulsion injuries. In the caries and internal resorption on periapical
absence of bacteria, the resorption is revers- images (Fig. 22.24).
892 S.L. Doyle et al.
b c
Fig. 22.22 Reformatted panoramic (a), and serial cross- trauma. The images show bone trabecular-like replace-
sectional (b) and coronal (c) CBCT images of a root-filled ment of the superior and palatal aspects of the apex con-
maxillary right central incisor with a previous history of sistent with external replacement resorption
a b
Fig. 22.23 Rendered volumetric image (a) of 14-year- (b) show the irregularity of the mesial surface this tooth
old with a history of luxation of the deciduous maxillary and loss of PDL space suggestive of replacement resorp-
right central incisor and failure of eruption of the associ- tion. Note concomitant external root resorption extending
ated permanent central incisor. Sequential axial images to the pulp canal
Heithersay (2004) reported a clinical classifi- 2006). IRR has been associated with a history
cation of invasive cervical root resorption based of trauma, caries and periodontal infections,
on increasing severity (Table 22.2). pulpal inflammation and orthodontic treat-
ment (Haapasalo and Endal 2006; Caliskan
Internal Root Resorption (IRR) and Turkun 1997; Patel et al. 2010b). Accurate
IRR is an inflammatory process that initiates assessment is essential as treatment regimens
within the pulp space and results in the loss of may vary. Differentiating between IRR and ERR
internal tooth structure. Compared with ERR, may be challenging using periapical radiography
IRR is relatively rare (Haapasalo and Endal alone.
22 Endodontic Applications of CBCT 893
a b c
Fig. 22.24 Unremarkable periapical image of the man- crowding. Right (b) and left (c) cross-sectional and axial
dibular left anterior teeth (a) of a patient with history of (d) CBCT images showing early (Class I) ERR on the left
previous orthodontic revision for mandibular anterior and right canines
Table 22.2 Classification of invasive cervical resorption On CBCT, characterization of root resorption
(Heithersay 2004) is determined by location of the resorptive defect.
Classification Description IRR usually appears as a round or oval-shaped
Class 1 Small, invasive resorptive lesion radiolucent “ballooning-out” of the root canal
characterized by shallow penetration and has smooth, well-defined regular margins
into the dentin near the cervical area
(Figs. 22.26, 22.27, 22.28, and 22.29).
Class 2 Well-defined, invasive resorptive
lesion that has penetrated close to the
coronal pulp chamber but has little or 22.3.3.7 Periapical Non-dental
no extension into the radicular dentin Associated Conditions
Class 3 Deeper invasion of the dentin that
involves the coronal dentin and
Anatomic Features
extends into the coronal third of the
root (Figs. 22.25 and 22.26) Numerous anatomic landmarks of the jaws may
Class 4 Large invasive resorptive process that resemble periapical pathoses of dental origin,
has extended beyond the coronal third most of which are low density. The most impor-
of the root 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 on the undisturbed PDL space. CBCT imaging
dental inflammatory conditions eventually result clearly identifies anatomical structures associ-
in widening of this space and are clinically asso- ated with the periapical regions including the
ciated with pain, particularly on dental occlusion inferior alveolar canal, the mental foramen and
or percussing the tooth. With chronic dentally nutrient canals in the mandible, and the incisive
related periapical pathoses, pain may or may fossa and the maxillary sinus in the maxilla. The
not be a symptom; however, there is generally a incisive fossa may contain the foramina of Sten-
remodeling of the apical periodontal space with son and Scarpa, adding additional uncertainty
an apical radiolucency having walls that merge when these features are projected on the apices
with the lamina dura. By way of comparison, of the maxillary central incisors using intraoral
normal anatomic landmarks are superimposed 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
a b c d
Fig. 22.30 Periapical intraoral image (a) and parasagittal an area of low density on the lingual aspect of the distal
(b), cross-sectional (c) and axial (d) CBCT images of a root involving the lingual exostosis. Also note the buccal
patient referred for evaluation due to discomfort in right exostosis. Biopsy confirmed necrotic bone consistent with
mandibular area. Clinic examination and vitality testing sequestra. The teeth have remained vital at the 2-year
were all normal with the exception of palpation tender- checkup
ness on the lingual of molars. CBCT images demonstrate
while usually round, may be flat, spindle- MacDonald-Jankowski 1999) localized intra-
shaped, nodular or lobular in shape. medullary well-defined irregular hyperdensity
–– Mandibular Torus. These occur on third as located in the mandibular molar and premolar
frequently as torus palatinus and present as areas and usually associated with a tooth hav-
bilateral exostoses on the lingual alveolar ing a vital pulp. They may present radiograph-
crestal surface, adjacent the mandibular ically as (Yonetsu et al. 1997):
premolars. –– Enostosis (E type). This present as a local-
–– Alveolar Exostoses. Other less common ized homogeneous thickening of either the
exostoses of the alveolar cortical plate buccal or lingual cortical bone in a particu-
include palatal (palatal aspect of the maxil- lar area.
lary alveolus) or buccal (buccal alveolus of –– Central sclerosis (CS type). This may pres-
either jaw) (Fig. 22.30) (Jainkittivong and ent as a solitary radiopacity in the medul-
Langlais 2000; Horning et al. 2000). lary bone without attachment to the internal
• Enostosis. An enostosis is an intramedul- margin of the cortical bone. This type can
lary growth of compact bone or a mixture of be further divided into homogeneous and
compact and cancellous bone from the inner heterogeneous subtypes.
aspect of the facial and lingual cortical plates, • Impacted tooth elements. Numerous entities in
often occurring in the mandibular canine and proximity to or superimposed on the roots of
premolar area inferior to the apices of teeth. the dentition include impacted and submerged
While radiographically indistinguishable from retained root fragments (deciduous or perma-
osteosclerosis, it may simulate other more nent), microdontic teeth or developing teeth
aggressive conditions such as osteosarcoma. (Fig. 22.31). Most present radiographically as
• Idiopathic Osteosclerosis. This condition, a homogeneous hyperdensity with the shape
also called focal periapical osteopetrosis or of a tooth or root, a thin pericoronal or PDL
dense bone islands, is an infrequently occur- space, and a central linear hypodensity sug-
ring (range, 4.1–6.7% (Geist and Katz 1990; 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 899
Table 22.3 Examples of pathology associated with tooth apices, not necessarily odontogenic in origin.
Border Radiolucent Radiopaque Radiomixed
Unilocular • Nasopalatine canal duct cyst • Odontoma (compound • Focal COD (intermediate)
and complex) (Fig. 22.34)
• Lateral periodontal cyst (Botryoid • Focal cemento-osseous • Cementoblastoma
odontogenic cyst) dysplasia (mature)
• KOT (early) (Fig. 22.32) • Osteoblastoma
• Central giant cell granuloma • Osteosarcoma
(Fig. 22.33)
• Aneurysmal bone cyst
• Traumatic bone cavity
• Focal COD (osteolytic)
Multilocular • Keratocystic odontogenic tumor • Florid COD (mature) • Florid COD (mature)
• Ameloblastoma
• Central giant cell granuloma
• Odontogenic myxoma
KOT keratocystic odontogenic tumor, COD cemento-osseous dysplasia
900 S.L. Doyle et al.
a b
c d e
Fig. 22.32 Periapical image (a) of patient referred for density with buccal cortical perforation (radiographic sign
evaluation of soft tissue swelling in the maxillary right of aggression) with no change in PDL space.
canine area. Pulp testing was normal. Volumetric render- Histopathology reveals a keratocystic odontogenic tumor.
ing (b), axial (c), parasagittal (d), and cross-sectional (e) Entities in this region, with various histopathology, had
CBCT images demonstrate a unilocular apical area of low previously been referred to as “globulomaxillary cyst”
sinusitis can be classified into two types • Fungus ballor fungal mycetoma is an extramu-
(Aribandi et al. 2007): cosal fungal proliferation, mostly caused by
• Noninvasive or allergic fungal sinusitis, usu- Aspergillus spp., often involving the maxil-
ally presents with involvement of multiple lary sinus (Pagella et al. 2007). Many patients
sinuses, mimicking pansinusitis and associ- present with a history of facial pain or rhi-
ated rhinitis, with near-complete opacifica- norrhea and a history of previous endodon-
tion. Peripheral bony expansion with erosion tic treatment. Aspergillosis of the maxillary
is an important imaging feature. sinus has been reported in association with
22 Endodontic Applications of CBCT 901
a b
c d e
Fig. 22.33 Premolar (a) and molar (b) periapical images Pulp testing was within normal limits. Parasagittal (c),
of an asymptomatic patient undergoing active orthodontic axial (d), and cross-sectional (e) CBCT images show a
therapy referred for evaluation of the mandibular right large, well-defined, non-corticated periapical area of low
quadrant. These images show a generalized area of rar- density with buccal cortical expansion, furcation involve-
efaction in the interradicular bone between the first molar ment and thinning. Histopathology reported a central
and second premolar but no changes in the lamina dura. giant cell granuloma
a b c d
Fig. 22.34 Periapical image (a) of asymptomatic middle- buccal expansion without perforation of the cortical plate.
aged African-American female referred for evaluation of Together with the history, the imaging appearance is most
mixed hyper- and hypodensity associated with the apices consistent with focal cemento-osseous dysplasia
of both mandibular right premolars. Parasagittal (b), (intermediate)
cross-sectional (c), and axial (d) images show associated
902 S.L. Doyle et al.
a b
Fig. 22.35 Parasagittal (a) and cross-sectional (b) CBCT lesion, antral mucosal pseudocysts do not disrupt the floor
images showing typical homogeneous dome-shaped of the sinus nor expand superiorly from the apices of the
appearance of an antral mucosal pseudocyst. Unlike peri- roots of adjacent teeth
apical mucositis, which is associated with a periapical
extrusion of root canal material with cer- –– Associated with a tooth having pulpal dis-
tain cements (Khongkhunthian and Reichart ease whose apices approximate the floor of
2001; Giardino et al. 2006). There is almost the maxillary sinus.
total opacification of the sinus, with sclero- –– The presence of a periapical radiolu-
sis and thickening or expansion and thinning cency with the involved tooth (periapical
with focal areas of erosion from pressure osteoperiostitis).
necrosis occurring in approximately 1/3rd of –– Radiographic loss of the lamina dura at the
cases. The unique appearance of metallic or inferior border of the maxillary sinus over
highly calcified central, punctate, hyperdense the involved tooth.
calcifications within an opacified sinus cavity –– Periapical mucositis. Localized reactive,
is considered a characteristic finding. relatively hyperdense soft tissue swelling
and thickening of the sinus mucosa above
Extrinsic Sinus Disease the apex of a pulpally involved tooth. The
Dental infection may often be a major predis- apical lesion may displace periosteum
posing factor in the development of maxillary resulting in a “halo” of thin peripheral
sinusitis. This may be due to an oroantral fistula, layer of new bone (Bornstein et al. 2012;
secondary to periapical, periodontal or pericoronal Vogiatzi et al. 2014) (Fig. 22.36).
disease or associated with endodontic treatment –– Maxillary sinusitis of dental origin
(Engström and Ericson 1964; Legert et al. 2004). (MSDO). MSDO (Bauer 1943) has been
reported to account for approximately
• Endo-Antral Syndrome (EAS) (Selden 1989, 5–10% (Maloney and Doku 1968; Mehra
1994, 1999). This results from the spread of and Murad 2004; Vogiatzi et al. 2014) and
pulpal disease beyond the apex into the max- even more than 50% (Malliet et al. 2011;
illary sinus. CBCT clearly demonstrates the Lu et al. 2012) of all cases of sinusitis and
features of EAS (Angelopoulos 2008; Patel presents as partial or complete opacifica-
et al. 2007b; Shanbhag et al. 2013), which is tion of the lumen of the maxillary sinus
characterized by one or more of the following: (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 (d) CBCT images show a periapical hypodensity associ-
maxillary pain shows partial elevation of the floor of the ated with an untreated MB2. The lack of cortical integrity
maxillary sinus and loss of lamina dura adjacent to the superior to the MB root and accompanying partial opaci-
apex of the mesiobuccal root of the endodontically treated fication with surface air locules is consistent with acute
first molar. Axial (b), parasagittal (c), and cross-sectional MSDO
a b
DRAINAGE
c d
Fig. 22.38 Intraoperative periapical image (a) of a max- the incisive canal. A cross-sectional CBCT image (d) with
illary left central incisor with an instrument inserted into gutta percha inserted into the canal shows the mechanical
the root canal after initial mechanical preparation through preparation was directed palatally. The access was redi-
a calcified obstruction in the mid third of the root. Axial rected facially, resulting in negotiation of the canal to the
(b) and cross-sectional (c) CBCT images with gutta per- apex
cha placed in the palatal sinus tract shows involvement of
906 S.L. Doyle et al.
• Evaluation of unexpected anatomic findings. The benefits of the additional diagnostic infor-
• Identification of missed canals in endodontic mation provided by intraoperative CBCT in select
retreatment. cases justify the risk associated with the limited
• Evaluation of root resorption and root level of radiation exposure (Ball et al. 2013). The
fractures. AAE and AAOMR (2015) state:
• Assessment of possible iatrogenic errors such If a preoperative CBCT has not been taken, limited
as perforation, fractured instruments, and FOV CBCT should be considered as the imaging
extruded obturation materials (Figs. 22.39 modality of choice for intra-appointment identifi-
and 22.40). 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 907
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; shown that healed rate for CBCT is much lower
Estrela et al. 2008b; Christiansen et al. 2009; than for periapical images (Patel et al. 2012b).
Peters and Peters 2012). Various indices and scales to assess outcomes
Periapical images may therefore result in an with CBCT have been proposed (Estrela et al.
overestimation of favorable outcomes (Wu et al. 2008c; Venskutonis et al. 2015) including api-
2009). The use of CBCT provides a more objec- cal lesion area or volumetric analysis (Alhowalia
tive representation of dynamic osseous changes et al. 2013; Van der Borden et al. 2013; Metska
over time (Pinsky et al. 2006; Patel et al. 2007b, et al. 2013) which appear to provide reliable
2015; Kaya et al. 2012). However, outcome results. Other factors affecting treatment out-
assessment may be complicated as some healthy comes such as root canal length and radiodensity
teeth demonstrate a widened PDL space on CBCT (Ng et al. 2008) can also be determined. Liang
(Pope et al. 2014). In addition, investigators have et al. (2011) found 80% of apparently short apical
22 Endodontic Applications of CBCT 909
a c d e
Fig. 22.42 Cross-sectional CBCT image (a) and surgical with bone graft, cross-sectional and parasagittal CBCT
photograph (b) of a symptomatic patient showing a large images immediately postoperative (c), 6 months and
periapical lesion associated with an endodontically treated 3.5 years (d) after surgery show excellent healing
maxillary left central incisor. After apical microsurgery
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- (the ability to detect confirmed VRF) than peri-
ical, since VRF can have a rapid and extensive apical radiography, particularly when a voxel size
effect on the surrounding periodontium and osse- smaller than 0.2 mm is used (Ozer 2011; Corbella
ous bone (Walton et al. 1984). et al. 2014). In addition, CBCT with smaller fields
Numerous ex vivo (in vitro) experiments (Has- of view have higher accuracy and sensitivity for
san et al. 2009, 2010; Melo et al. 2010; Ozer 2011; detecting VRF than larger fields of view (Bechara
da Silveira et al. 2013; Patel et al. 2013; Brady et al. 2013). The type of CBCT scanner may also
et al. 2014; Junqueira et al. 2013; Jakobson et al. affect the reproducibility and accuracy of VRF
2014), clinical (in vivo) studies (Edlund et al. detection (Hassan et al. 2010; Metska et al. 2012).
2011; Wang et al. 2011; Metska et al. 2012), and The presence of radiopaque obturation mate-
case series (Bernardes et al. 2009) have compared rials and/or posts in the root canals of endodon-
the efficiency of CBCT and intraoral radiography tically treated teeth may cause radiographic
for the detection of VRFs. These studies indicate artifacts such as beam hardening and streak arti-
that CBCT has similar specificity (the ability to facts that can interfere with the definitive iden-
detect the absence of VRF) but higher sensitivity tification of a fracture (Junqueira et al. 2013;
22 Endodontic Applications of CBCT 911
Corbella et al. 2014; Jakobson et al. 2014; Neves in detecting VRF in root-filled teeth (Talwar et al.
et al. 2014). In these situations, removal of canal 2016). In regard to the use of CBCT for VRF, the
materials may potentially enhance the detection AAE and AAOMR (2015) state:
of VRFs (Ball et al. 2013). Limited FOV CBCT should be considered the
Despite the limitations of CBCT, it can be imaging modality of choice if clinical examination
a valuable adjunct for the diagnosis of VRF and 2-D intraoral radiography are inconclusive in
(Patel et al. 2015; Corbella et al. 2014; Chavda the detection of VRF.
et al. 2014; Chang et al. 2016). The usefulness Further research is needed to investigate the
of CBCT may be more likely related to spe- effect of changes in periradicular bone patterns,
cific changes in the periradicular bone patterns the experience of observers, the resolution of the
associated with an undetected VRF than in the CBCT images, and image interval thickness in
actual visualization of the fracture in the root the radiographic diagnosis of VRF (Cohenca and
structure. The authors of a recent meta-analysis Shemesh 2015).
of the role of CBCT in the diagnosis of VRF
stated that CBCT scans showed better sensitiv- Perforation
ity and specificity than periapical radiography in Iatrogenic root perforations are complications
unfilled teeth, especially when with a voxel size that may occur during endodontic treatment
of 0.2 mm. CBCT showed low pooled sensitivity (Fig. 22.44) or subsequent post preparation or pin
a b
c d
Fig. 22.44 Periapical image (a) of endodontically treated access during attempt to negotiate the MB2 canal and
maxillary right first molar with intermittent symptoms. mesial vertical marginal alveolar defect. The patient opted
Sagittal (b), axial (c), and cross-sectional (d) CBCT for extraction and symptoms resolved
images demonstrate furcal perforation due to misguided
912 S.L. Doyle et al.
insertion (Fig. 22.45). Treatment involves imme- prognosis, and subsequent treatment (Young
diate sealing of the perforation and prevention of 2007; Shemesh et al. 2011; Kamburoğlu et al.
infection using nonsurgical, surgical, or a combi- 2015). Dynamic visualization by axial image
nation of approaches. Prognosis depends on the scrolling or “map reading” (Bueno et al. 2011)
time of occurrence, size, location, and material may provide an optimal interpretation strategy.
used to repair the perforation (Fuss and Trope In regard to detection of endodontic complica-
1996; Siew et al. 2015). tions, the AAE and AAOMR (2015) state:
Radiographic detection of perforations involv- Limited FOV CBCT should be the imaging modal-
ing the labial or lingual root surface is challeng- ity of choice for nonsurgical retreatment to assess
ing, even using a tube shift technique (Goerig endodontic treatment complications, such as over-
and Neaverth 1987). CBCT may facilitate in extended root canal obturation material, sepa-
rated endodontic instruments, and localization of
the determination of the nature of a perforation, perforations.
a b
c d
Fig. 22.45 Periapical image (a) of a patient who presents Sagittal (b), cross-sectional (c), and axial (d) CBCT
with a low-grade ache and mild tenderness to percussion images demonstrate an area of low density lingually and
associated with the left second mandibular premolar. perforation of a restorative pin
22 Endodontic Applications of CBCT 913
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