Current Oral Health Reports

https://doi.org/10.1007/s40496-019-00239-0

MODERN APPROACHES TO ENDODONTICS (S KIM AND B KARABUCAK, SECTION EDITORS)

The Use of Cone Beam Computer Tomography (CBCT) in Endodontics

Meetu R. Kohli 1 & Tom Schloss 1,2

# Springer Nature Switzerland AG 2019

Abstract
Purpose of Review Cone beam computed tomography scans have been gaining popularity as a diagnostic aid. The purpose of this
review is to understand the benefits and the limitations of this technology and its application in day to day clinical assessment.
Familiarity with some basic principles of the technical aspect will aid the practitioner in controlling quality of the scan and the
amount of radiation the patient is subjected to.
Recent Findings Significant findings of this review are that the exposure to ionizing radiation is the main limiting factor in taking
CBCT scans. The information obtained can be invaluable in treatment planning by providing a three-dimensional view of teeth
and neighboring structures. The sensitivity of a scan to identify low radiodensity areas is significantly higher than two-
dimensional X-rays; however, the histological nature of the affected bone is still being investigated.
Summary In summary, while the clinician should weigh the risk and benefit before obtaining a scan, the industry should evaluate
technology to reduce the exposure to radiation per scan further.

Keywords Cone beam computed tomography . Current standards . Limitations . Advantages . Guided endodontics

Introduction roots of premolars and be misinterpreted as a pathology where

Radiography is an essential diagnostic aid in dental medicine.
Objective and subjective tests along with radiographic evalu-
ation of the targeted tissue are imperative to reach accurate
diagnosis and hence treatment plan. In endodontics, 2D imag-
ing with multiple radiographs has traditionally helped the cli-
nician to arbitrarily construct a mental three-dimensional im-
age of the tooth with its surrounding anatomy. Dental radio-
graphs have several limitations: it is a 2D representation of a
3D structure; hence, superimposition of unrelated structures or
structures of lower interest is included in the image contribut-
ing to anatomic noise. These anatomical landmarks such as
zygomatic arch might superimpose and make the area of in-
terest, e.g., maxillary molars difficult to read or structures such
as mental nerve on the lower mandible may superimpose on
This article is part of the Topical Collection on Modern Approaches to
Endodontics
* Meetu R. Kohli
mkohli@upenn.edu
1
Department of Endodontics, University of Pennsylvania School of
Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
2
Berlin, Germany
non-exists. To compensate for these limitations, parallax tech-
niques using Clark’s rule or Richards’ buccal object rule are
recommended, and a variant of this is to take 3 radiographs:
one straight on buccolingual direction with paralleling tech-
nique and other two with 10–15-degree mesial and distal hor-
izontal angulations. These three images will allow the clini-
cian to construct a 3D image of the area of interest mentally.
Besides the capture of the dental X-ray image, the interpre-
tation of these images comes with its own limitations. These
have been recognized as far back as 1970s when a series of
investigations by Goldman et. al. unequivocally demonstrated
the difficulty in interpretation of the dental radiographs. The
study was conducted to evaluate agreement between radiolo-
gist and endodontist in reading of several radiographs. The
most interesting step of investigation was published in a sub-
sequent manuscript wherein the radiologist and endodontist
were asked to review the same radiographs after 6–8 months
and they agreed with themselves only 72–88% of the time [1],
proving that there are errors in interpretation of radiographs
that can be problematic.
Computed tomography (CT) scans have been used in var-
ious medical fields for several years; however, their use in
endodontics was limited due to high cost, availability, and
total radiation received. The risk to benefit ratio has been
prohibitory. However, the cone beam CT technology has

reduced the radiation dosage by 50–70 times that of a medical
scanner. The size of the machine makes it easily installable
and readily usable in a dental office setting. As the use of
tomography becomes popular, it raises questions about its
application and interpretation. The following discussion will
address these concerns and discuss the latest evidence.
Technical Aspects of Acquiring a CBCT Scan
Familiarity with the operational parameters of the apparatus
can help the practitioner in two key clinical areas, one being
radiation dosage and the other image quality. A thorough as-
sessment of radiation safety is paramount when a new imag-
ing technology is introduced. The manufacturers are compet-
ing to improve performance of their respective machines to
get the best possible image with minimal radiation dose.
The basic four components of CBCT image production are
(A) acquisition configuration, (B) image detection, (C) image
reconstruction, and (D) image display [2•].
A. Image acquisition: The acquisition of the image in-
volves an X-ray generator and a detector revolving
synchronously around a fulcrum in the patient’s head
(usually the tooth in question) either in partial (180°)
or a full rotation (360°). In a conventional CT scan, a
fan-shaped beam is used to sequentially acquire a
single 2D slice of the object being scanned. As the
X-ray beam travels helically around the object several
times, the radiation dose is large and the time taken
for the scan is long. In cone beam technology, the X-
ray beam used is a divergent cone-shaped or recently
a pyramid-shaped ionizing radiation directed through
the middle of the region of interest. In contrast to a
conventional CT in a CBCT, a single rotation arc of
180 or 360° will acquire multiple (150–599) sequen-
tial planar projections of the field of view called the
raw or basis images. These images are 2D images
slightly offset from each other [3]. These are stacked
together to form the projection data.
B. Image detection: Flat panel detector is the most com-
monly used X-ray sensor with CBCT, which is com-
posed of a large area of pixel arrays [4]. Unlike a
regular CT where the slice thickness determines the
resolution of the image, in CBCT, the resolution is
determined by the pixel size on these detectors.
C. Image reconstruction: The raw signal is converted into a
single digital volume described by its smallest subunit
called the voxel, which are stacked in rows and columns
for visualization. CBCT voxels are isotrophic (cuboidal)
and range from 0.07 to 0.4 mm per side in size and is
assigned a gray-scale value that corresponds to the atten-
uation value of the represented tissue. As the voxels are
Curr Oral Health Rep
isotrophic, the image is never degraded when resliced in
any direction [2•].
D. Image visualization: A visualization software is inte-
grated wherein the digital data is displayed for inter-
pretation on a display monitor. The data can be
projected in 3 planes—axial, sagittal, and coronal. A
3D reconstruction of the dataset is a valuable feature
to visualize anatomy. Utilizing the various features
provided in the software will help the clinician use
the volumetric data to its full potential.
Benefit and Limitations of a CBCT Scan
Tooth Anatomy Studies Since the use of CBCT in endodon-
tics, a series of investigations have been undertaken and pub-
lished to evaluate the anatomy of the tooth and its neighboring
structures. The investigations have been done in various coun-
tries and ethnicities to assess similarities and patterns in these
groups [5, 6]. There is a trend to update the information that is
available to us in the literature. The older dental investigations
of root canal anatomy were on extracted teeth that were col-
lected and then either stained with India ink or sectioned
horizontally/vertically or cleared for assessment [7–9]. A lim-
itation of these studies is that teeth were evaluated post-extrac-
tion, which may or may not be representative of the true pop-
ulation, as the sample studied are teeth that were made avail-
able to the investigator only when they were lost. The clearing
and sectioning methodology is a valid methodology to study
root anatomy. The accuracy of CBCT scans to evaluate anat-
omy has been compared with traditional clearing or sectioning
techniques and has been found to be similar in accuracy [10,
11]. CBCT scans have since been evaluated to study anatomy
of teeth representative of groups, e.g., Lebanese, Chinese,
Korean, Japanese, and others for incidence of features that
are common to them such as C-shaped canal, number of ca-
nals, and the location of orifices [12–17]. These are teeth that
are functional and retained in the mouth hence a true repre-
sentative of the population being studied. Besides the anatomy
of the teeth, CBCT also allows the study of the proximity of
other anatomical structures in the area. This information can
be used preoperatively to treatment plan the procedure with
more accuracy and avoid iatrogenic errors. A presurgical
three-dimensional scan has become especially important for
surgical treatment planning and execution. In the past, the
surgeon performed surgery blind with no knowledge of depth
of the cortical plate, roots etc., just an estimation gained from
multiple radiographs. Now with a preoperative scan, the entire
surgery can be planned prior to execution. In some cases, if the
anatomy is found to be inaccessible, the treatment plan can be
changed accordingly to a plan that is more viable and predict-
able. Several investigations have been conducted to study the
Curr Oral Health Rep
depth of bone, location of the mental nerve, sinus cavity, and
proximity of the roots in the mandible and maxilla of a large
population to understand norms and variations that exist
[18–20].
Treatment Planning Treatment options for an endodontic case
especially a failing root canal therapy are many, from non-
surgical retreatment, surgical revision, root resection, or ex-
traction. A decision is dependent on understanding the etiolo-
gy for the persistent pathology, its extent, and access to it.
Multiple X-rays have been used to aid in evaluation; however,
a CBCT with multiplanar visualization provides information
that can change the treatment option chosen by the same op-
erator 50% of the time after viewing the CBCT. The decision
to extract increased by 20% after reviewing a CBCT scan,
avoiding an endodontic procedure that might have been un-
necessary and wasteful [21]. The execution of the treatment
option also becomes predictable and targeted towards e.g. a
missed canal or a perforation repair. Nudera suggested selec-
tive non-surgical retreatment of roots with periapical patholo-
gy only, as CBCT allows individual assessment of roots for
pathosis and retreatment can be limited to root or roots with
disease in multirooted teeth. This non-surgical approach mir-
rors surgical revision wherein only root or roots that are af-
fected are addressed [22]. A treatment option between surgery
and non-surgical retreatment might change based on the ac-
cess to the root. A surgical treatment might seem the best
option for a case but difficulty in access suggests another
treatment alternative [23]. Cracks are a significant finding as
the results are usually catastrophic; however, as many inves-
tigations have shown, CBCT will not necessarily help with
detection of a crack. The sensitivity to detect one in an unfilled
tooth is higher (0.77–0.94) especially when the voxel size is
0.2 mm. Filled teeth have the disadvantage of the beam hard-
ening and other noise and scatter that makes interpretation of
the image difficult [24]. Although cracks or fractures are not
always distinctly visible on CBCT scans, the pattern of bone
loss observed along with clinical evaluation of multiple sinus
tracts or single deep probing might be indicative of one. These
factors can affect treatment plan.
Detection of AP A 2D radiographic detection of a periapical
pathology is limited by the effect it has on the cortical bone.
According to IB Bender et al. [25], a lesion when contained
within medullary bone will not present itself on an X-ray as the
total mineral loss is not significant to be detected as a radiolu-
cent image. Once the lesion encroaches the cortical plate lead-
ing to additional mineral loss, it will become distinctly visible
on periapical film. CBCT allows for detection of minor changes
in the periapical region unlike X-ray. Most studies comparing
detection of periapical periodontitis (PAP) on intraoral radio-
graphs vs CBCT show a difference of approximately 20%
[26–28]. A meta-analysis of 6 studies investigating detection
of artificially induced bone defects showed an accuracy value
of 0.96 for CBCT, 0.73 for conventional periapical radiography,
and 0.72 for digital periapical radiography [29]. The question
however remains whether every low radiodensity area present
on CBCT is histologically an inflamed area. Are all low-density
zones representative of inflammatory process? Will the CBCT
detection of lesions lead to more invasive treatment modalities
hence overtreatment? There are very few investigations in our
literature that compare histologically what is detected on a scan.
Kanagsingam et al. evaluated 67 teeth in fresh cadaver jaws.
The images were obtained with a single straight beam radio-
graph and with 10-degree M and D inclination and a CBCT
scan. The teeth were not endodontically treated. Fifty-eight of
the 67 teeth had lesions; histologically CBCT had a positive
predictive value of 1, suggesting that when a lesion was seen on
CBCT, histologically inflammation was confirmed. The nega-
tive predictive value in this study was 0.81 to be interpreted as
the disease was not detected 19%. However, the limitation of
the paper could be the fact that out of 67 teeth studied, only 10
were molars. Another investigation that reflects the diagnostic
accuracy of CBCT imaging technique with the valid standard of
histology for 335 roots for both filled and unfilled teeth in
cadavers concludes in unfilled teeth when a small or “unsure”
lesion was detected on CBCT, the histological evaluation usu-
ally detected inflammatory cells. However, when the tooth is
filled smaller lesions might not be histologically an inflamma-
tion. As this investigation was conducted on cadavers, clinical
data of signs and symptoms has not been corroborate, which
might help with diagnostic accuracy [30].
New Indices As probability of detection of AP becomes
higher with 3D scans, new indices are needed to quantify
the presentation of the lesion. Radiographic assessment
has been historically evaluated by either Strindberg’s
criteria or more commonly by Ostravik’s PAI index. PAI
index is 6-point graded score from health at 0 to severe
apical periodontitis at 5. Estrela used the PAI index to
create a CBCTPAI with 2 additional variables. The lesion
is evaluated in three planes, MD, BL, and diagonal, the
largest extent of the lesion is used for grading the AP.
Another variable of E (expansion of cortical plate) or D
(destruction) is also reported along with the point grade.
These two features cannot be evaluated on a periapical
film. The CBCTPAI can be used not just to report the
extent of a lesion but also check for improvement or fail-
ure at follow-up [31].
Similarly, a criteria for evaluation of surgical treatment
has been proposed, Penn 3-Dimensional criteria [28•].
The most commonly used criteria for success used in
prognostic literature is either Molven or Rud’s criteria
for radiography; however, as CBCT shows additional pla-
nar information, the Penn criteria addresses them (Table 1,
Figs. 1, 2, and 3). The 3 categories are based on Rud and

Table 1 Penn criteria for
evaluating 3D scans of teeth Complete healing
following endodontic
microsurgery
Limited healing
Unsatisfactory healing
Molven’s. Category A shows various scenario representa-
tions of successful outcome. Category C is failure while
category B is representative of outcomes that show dis-
tinct change from post-operative scan with dramatic
healing but not a complete regeneration of periapical tis-
sues. As CBCT is becoming a common tool to evaluate
AP, it reflects in our evaluation of prognosis of treatment
as well [32]. Davies et al. in their prospective study on
evaluation if non-surgical endodontic retreatment had a
93% successful outcome when undertaken with routine
radiographs while 77% when assessed with CBCT [33].
Surgical outcome assessment also has a similar trend,
while the radiographic success was higher at 93.3%;
CBCT evaluation shows more low-radiodensity areas with
the reported success rate of 85% [28•, 34, 35]. These
findings now raise the question whether CBCT healing
should be evaluated at longer intervals to allow for further
changes to occur in the total volume of the lesion as
assessed in three dimensionally (Fig. 4).
Guided Endodontics Guided surgical procedures have been
long used and fine-tuned in the medical field. With
Fig. 1 a–e Penn criteria for evaluating 3D scans of teeth following endodontic microsurgery. Complete healing
Curr Oral Health Rep
A—Reformation of periodontal space of normal width and lamina dura over
the entire resected and unresected root surfaces
B—Slight increase in width of apical periodontal space over the resected root
surface, but less than twice the width of non-involved parts of the root
C—Small defect in the lamina dura surrounding the root-end filling
D—Complete bone repair with discernible lamina dura; bone bordering the
apical area does not have the same density as surrounding non-involved bone
E-Complete bone repair. Hard tissue covering the resected root-end surface
completely. No apical periodontal space can be discerned
A—The continuity of the cortical plate is interrupted by an area of lower density
B—A low density area remains asymmetrically located around the apex or has
an angular connection with the periodontal space
C—Bone has not fully formed in the area of the former access osteotomy
D—The cortical plate is healed but bone has not fully formed in the site
The volume of the low density area appears enlarged or unchanged
adoption of CBCT and ability to topically scan the tissue
with a 3D scanner and 3D printer has made guided end-
odontics the latest technological advancement being ex-
plored in endodontics. Targeted or guided endodontics
has found use in both surgical and non-surgical proce-
dures. The main advantage is to be minimally invasive,
the access to the area to be treated is small, less invasive,
and hence less destructive and may lead to faster healing.
A guided stent is printed after combining the STL files
obtained from a 3D optical scan of the tissue and com-
bining it with the 3D radiographic assessment from a
CBCT scan. The prefabricated stent acts as a guide to
direct burs/drills to the targeted area with minimal error.
In an experimental model by Pinsky et al., the examiner
deviated by 2 mm 70% of the time and by 3 mm 22%
from approaching the root tip during apicoectomy. The
deviation with guidance was 0.79 mm (0.33 SD) [36]. In
targeted surgery, the technique has been further advanced
to use a hollow trephine rotated within the 3D printed
surgical guide port to conduct a single-step osteotomy,
root-end resection, and biopsy [37]. This has allowed
easy surgical access to roots of second molars and palatal
Curr Oral Health Rep
Fig. 2 a–d Penn criteria for evaluating 3D scans of teeth following endodontic microsurgery. Limited healing
roots of upper molars, surgeries that were not considered
due to unpredictable execution. In non-surgical treatment,
the procedure finds use in calcified cases. The guided
stents can help drill through a calcified root fast and safe
without iatrogenic errors [38]. The technology is very
new and still evolving especially if the treatment is for
molars and teeth with curved root canals.
Radiation Dosage The main concern with acquiring a
CBCT scan is the radiation dosage. Subjecting the patient
to radiation is unavoidable in diagnostic medicine. The
data acquired can change treatment plan and options for
the better. When benefits outweigh the risks, the exposure
to ionizing radiation can be justified. The radiation dosage
varies between scanner and is dependent on the size of
field of view, exposure time, current, and voltage. For
endodontic purposes, the small field of view is adequate.
The radiation dose from an exposure of small fov scan
varies from 19 to 44 μSv while a large fov can vary from
68 to 368 μSv. To put these numbers in perspective, a
single digital PA radiograph is about 1 μSv while regular
Fig. 3 Penn criteria for evaluating 3D scans of teeth following
endodontic microsurgery. Unsatisfactory healing
panorex X-ray is about 10 μSv and a digit one is about 20
μSv. However, these exposures are still smaller than med-
ical scans like a chest X-ray is 140 μSv and head CT is
2000 μSv. It is the responsibility of the clinician to be
consistent with the ALARA principle and expose the pa-
tient to a radiation dose “as low as reasonably achiev-
able.” This is especially of concern in children. The
Image Gently Campaign led by the Alliance for
Radiation Safety in Pediatric Imaging is supported by
the AAE as well. The goal of the campaign is “to change
practice; to raise awareness of the opportunities to lower
radiation dose in the imaging of children” [39••].
Currents Standards Established
by Endodontic Associations
American Association of Endodontics (AAE) and
American Academy of Oral and Maxillofacial
Radiology (AAOMR) provided an updated joint position
statement on scientifically based guidance to clinicians in
regards to use of cone beam tomography in 2015/2016
[39••]. The position statement suggests that when the
medical history and clinical exam indicate that the eval-
uation of 3D scan will outweigh the risks, a CBCT can
be taken. However, it is not recommended for routine
diagnosis and screening for signs and symptoms. As
the field of view dictates the radiation dosage the patient
is exposed to, the smallest field of view (fov) is recom-
mended. The smaller fov scans also have higher spatial
resolution and hence are more diagnostic as far as end-
odontic assessment is concerned. The endodontist
requesting the scan is responsible for the data collected
on the image and the statement advised the clinician to
refer to an oral and maxillofacial radiologist when in
doubt about interpretation of the data. The statement
has 12 recommendations for judicious use of CBCT
scans. The recommendations suggest that only a small
 Curr Oral Health Rep

Fig. 4 Examples of volumetric analysis of the periapical lesion using a CBCT scan

fov scan should be taken when indicated. A summary of and management of resorption, and presurgical assessment
those recommendations are as follows: for endodontic surgery.

1. 2D intraoral radiograph are still the imaging of choice.

2. Limited fov can be taken when the clinical signs and
Conclusions
symptoms are contradictory or non-specific.
3. Preoperative scan can be taken when unusual anatomy is
CBCT scans are an essential special test in many endodontic
considered.
situations and incredibly useful diagnostic tool available to the
4. An intraoperative scan is indicated when a calcified or
clinician today alongside the routine diagnostic information
missed canal is to be identified and located and a preop-
collected. The main cautionary consideration as outlined by
erative scan was not taken.
statements from various societies, and regulatory and academ-
5. Immediate post-operative X-ray remains the modali-
ic bodies is the exposure to ionizing radiation. The benefit of
ty of choice.
the scan must outweigh the risk involved. Thus, use should be
6. CBCT can be used when clinical exam and X-ray are
evaluated on a case-by-case basis.
inconclusive to detect vertical fractures and one is
suspected.
Compliance with Ethical Standards
7. A scan can be used to evaluate a failing root canal treat-
ment to evaluate reasons for failure and treatment plan Conflict of Interest The authors declare that they have no conflicts of
for further intervention. interest.
8. A scan can be acquired to assess endodontic treat-
ment complications, such as perforation, overfill, and Human and Animal Rights and Informed Consent This article does not
separated files. contain any studies with human or animal subjects performed by any of
the authors.
9. A scan can be taken for presurgical treatment planning.
10. CBCT is the imaging modality of choice for surgical
placement of implants.
11. Diagnosis and management of dental trauma References
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