Oral Radiology

https://doi.org/10.1007/s11282-019-00390-5

REVIEW ARTICLE

Cone‑beam computed tomography imaging of dentoalveolar

and mandibular fractures
Ulkem Aydin1 · Ozlem Gormez2 · Derya Yildirim2

Received: 1 October 2018 / Accepted: 6 May 2019

© Japanese Society for Oral and Maxillofacial Radiology and Springer Nature Singapore Pte Ltd. 2019

Abstract
Three-dimensional imaging methods have an important role in the diagnosis of dentomaxillofacial fractures that can not
be seen on the plain films. Cone-beam computed tomography (CBCT) is one of the three-dimensional imaging methods
and has facilitated dental professionals’ access to cross-sectional imaging. CBCT units allow different technical parameters
and the data acquired by CBCT, can be reformatted. Osseous structures are correctly examined with this technique but the
technique is not useful for the examination of soft tissues. Therefore, the purpose of its use should be based on the expected
diagnostic gain. The aim of this review is to present the use of CBCT with different multi-planar reformatted sections and
three-dimensional reconstructions of dentoalveolar and mandibular fractures.

Keywords  Cone-beam computed tomography · Maxillofacial injuries · Fractures

Introduction objective of imaging examination is to depict the presence,

Maxillofacial region is one of the most traumatized regions
in the human body. The causes and prevalence of maxil-
lofacial trauma are diverse and vary among different popu-
lations. Accidents associated with traffic, sports, work and
home, domestic violence, and assaults comprise the main
causes [1–9]. Injury to the face may only affect the dentition
or the dentition together with adjacent tissues, and thus, inju-
ries range from isolated fractures to complex facial injuries
[1, 2, 7, 10, 11]. Radiographic examination is essential in
terms of obtaining information for initial diagnosis, treat-
ment planning and follow-up in traumatized patients. The
A part of the submitted manuscript was presented as a part of
a poster titled “Cone-beam computed tomography findings of
dentomaxillofacial fractures” at the “European Congress of
Radiology 2016” in Vienna Austria. https​://doi.org/10.1594/ecr20​
16/c-0711.
* Ozlem Gormez
ozlemgormez@hotmail.com
1
Department of Dentomaxillofacial Radiology, Cyprus Health
and Social Sciences University School of Dental Sciences,
Morphou, North Cyprus
2
Department of Dentomaxillofacial Radiology, Suleyman
Demirel University Faculty of Dentistry, Doğu Kampüsü,
Çünür, 32000 Isparta, Turkey
location, extent of fractures, displacement of fragments and
foreign objects as a result of trauma [2, 5, 7, 8, 10–17]. One
or more combination of plain films that are perpendicular
to each other are considered for the initial assessment of
maxillofacial trauma [5, 8, 12, 16].
Three-dimensional imaging methods such as computed
tomography (CT) and cone-beam computed tomography
(CBCT) are useful in the diagnosis of dentomaxillofacial
fractures and they allow visualizing three-dimensional
images while at the same time they eliminate superim-
positions, especially in the midface, which have complex
anatomic features [8, 10, 11, 13, 16, 18, 19]. CT is usually
the preferred imaging method in maxillofacial injuries as
usually patients are first brought to the emergency service
of the hospitals. In addition, CT provides better soft tissue
characterization compared with CBCT images and is man-
datory for the diagnosis of maxillofacial trauma with severe
injuries of the soft tissue [20–22]. CBCT, with its simple
technical design, low cost, and small space requirements,
has facilitated dental professionals’ access to cross-sectional
imaging with high spatial resolution [5, 7, 8, 10, 11, 14, 15,
19, 23–28]. Although a common problem with both imaging
techniques is the presence of metallic artifacts, various algo-
rithms and methods help reduce these artifacts in CT and
CBCT images. Beam hardening is one of the most prominent
sources of metallic artifacts, which is the process by the

13
Vol.:(0123456789)

absorption of low-energy photons in a polychromatic X-ray
beam when passing through metallic objects and increasing
in beam average energy level. Therefore, higher tube voltage,
which means higher X-ray energy, is associated with smaller
artifacts and CT has an advantage at this point [22, 29–33].
The aim of this review is to present the use of CBCT in
traumatized patients and show dentoalveolar and mandibular
fractures with different multi-planar reformatted CBCT sec-
tions and three-dimensional reconstructions.
CBCT
CBCT is based on a divergent cone- or pyramidal-shaped
X-ray beam and an imaging sensor that are used to produce
three-dimensional digital data acquisition [2, 5, 7, 10, 14,
15, 25, 34]. CBCT acquires all projection images in a single
rotation of the X-ray tube and detector around the patient’s
head, inherently reducing time for scan of the overall region
of interest [2, 5, 7, 15, 25]. The possibility of a single partial
rotation has advantages in reducing radiation exposure and
motion artifacts. CBCT voxels are isotropic so their size are
all equal in three dimensions (height = width = depth), and
that enables reorientation of the volumetric data set [2, 8,
35–37].
The main advantages of CBCT imaging are its easy appli-
cability, high resolution, real-size dataset with multiplanar
cross-sectional and three-dimensional reconstructions [14,
19, 25]. In addition, the radiation dose from CBCT is gener-
ally lower than CT scans of the dental area. But CBCT and
CT have different radiation dose implications depending on
the equipment and exposure parameters. For instance “low
dose” protocols on CT may bring radiation dose down signif-
icantly without relevant loss of diagnostic image information
and quality [38–40]. While the CBCT imaging is beneficial
for maxillofacial region, there are some limitations such as
small detector size causing limited field of view, low contrast
range, limited soft tissue information, increased noise from
scattered radiation, movement and truncation artifacts. In
addition, CBCT imaging cannot be used for the measure-
ment of the Hounsfield units (HU) [25].
CBCT units allow different voxel resolutions and field of
views, depending on the model [2, 20, 37, 41]. Selectable
field of view that captures only the necessary region to be
studied provides minimizing the radiation exposure to the
patient, in line with the “as low as diagnostically acceptable
(ALADA) concept”, a radiation safety principle which is a
modification of “as low as reasonably achievable (ALARA)
concept”. According to ALADA concept, mAs, and kVp set-
tings and high-definition/high-resolution parameters should
also be selected to obtain a diagnostically acceptable image
[5, 7, 42, 43]. Small, medium, and large field of views are
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Oral Radiology
used for scanning a few teeth, jaws and the maxillofacial
region, respectively [44].
As a volume of data has been acquired and stored by
CBCT, the data can be reformatted, and several different
types of images in oblique or curved image planes can be
synthesized by the operator on the computer without patient
reexposure, in addition to the images in the orthogonal
planes [2]. Contrast resolution is the ability to distinguish
between differences in tissue attenuation and to display them
with different gray levels in the radiographic image which
is measured in HU. HU values in CBCT imaging, show dif-
ferences due to patient-dependent factors such as size and
location of the patient, inhomogeneous tissues, and neigh-
boring tissues. CBCT images include image artifacts and
noise resulting from the scattered photons from inhomoge-
neous tissues. Therefore, it causes deterioration in image
uniformity and mislead HU values. At the same time, it is
difficult to compare the gray values resulting from different
machines due to the absence of a standard system for scaling
the gray levels representing the reconstructed values. For
this reason even though CBCT is mostly a tool for imaging
of the osseous structures, it cannot be used for the meas-
urement of the bone density. Also CBCT imaging does not
provide adequate gray-scale sensitivity to discern subtle dif-
ferences between soft tissues because of the reduced operat-
ing kilovolt (peak) and milliampere of CBCT compared with
CT. So it is not useful for the examination of soft tissues
[45–48]. Therefore, this technique should be used based on
the expected diagnostic gain [25].
CBCT provides important diagnostic information on
maxillofacial surgery, orthodontics, the bone pathoses,
impacted teeth, temporomandibular joint disorders, implant
planning and dentomaxillofacial fractures [14, 25, 26, 36].
The practice of oral and maxillofacial radiologists has
become more efficient and successful with CBCT, and this
technique is particularly well suited to image dentomaxillo-
facial fractures by providing detailed information [2, 7, 11,
20, 49]. In the literature, there are several studies evaluating
the dentomaxillofacial fractures with CBCT and comparing
the efficacy of CBCT with conventional radiography and CT
[15, 19, 20, 50, 51]. Eskandarlou et al. [15] compared CBCT
with multislice CT in diagnostic accuracy of maxillofacial
fractures in dried human skull. They have mentioned that
CBCT with small field of view had higher diagnostic accu-
racy in detecting fractures than multislice CT.
Moderate to high-resolution CBCT imaging has been
used to examine fractures. CBCT units provide submillim-
eter voxel resolution in all orthogonal planes. Some CBCT
units are capable of providing 0.076–0.125 mm voxel reso-
lution which may be required to examine root fractures [2,
44, 52]. In a case report, Dölekoğlu et al. [26] were able to
detect alveolar bone and root fractures by CBCT images
obtained with a voxel size of 0.2 mm that could not be seen
Oral Radiology
on panoramic radiograph and posteroanterior Reverse-
Towne projection.
CBCT imaging of dentoalveolar fractures
Root fracture involves the root of the tooth at any level and
usually is in a horizontal, diagonal or vertical plane. The
ability of a radiographic image to reveal the presence of
a root fracture depends on the angle of the X-ray beam in
relation to the fracture plane and the degree of separation of
the fragments. If the X-ray beam passes through the fracture
plane, a single, sharply defined radiolucent line is visible
on conventional radiographs. However, if the direction of
the X-ray beam to the fracture plane is oblique, the fracture
plane may appear as a more poorly defined single line and
can be overlooked or can be seen as two lines that converge
at the mesial and distal surfaces of the root [11, 16, 26, 27,
53, 54]. In some instances, the diagnosis of a root fracture
is difficult due to the variable clinical presentations and the
lack of pathognomonic signs. The only indication of a frac-
ture may be a localized widening of the periodontal ligament
space adjacent to the fracture site [16, 55–57].
The difficulties in detecting root fractures clinically and
with the aid of conventional radiography paved the way for
the studies assessing the performance of CBCT in the diag-
nosis of root fractures. A meta-analysis by Long et al. [57]
aimed at determining the diagnostic accuracy of CBCT for
tooth fractures in vivo. They have found the pooled sen-
sitivity as 0.92 and the pooled specificity as 0.85. A sys-
tematic review and meta-analysis, which has focused on
the detection accuracy of root fractures in CBCT images of
nonroot-filled teeth, reported the pooled sensitivity as 0.83
and the pooled specificity as 0.91 for i-CAT CBCT unit. The
pooled sensitivity was 0.96 and the pooled specificity was
0.95 for 3D Accuitomo CBCT unit [27]. Within this scope,
the influence of different voxel sizes on the detection accu-
racy of root fractures has also been investigated. According
to the results of a study by Özer [58], a 0.2 mm voxel was
the best protocol, considering the lower X-ray exposure and
good diagnostic performance. Da Silveira et al. [59] have
concluded that the root condition should guide the voxel
size choice, selecting 0.3-voxel for not root-filled teeth and
0.2-voxel for teeth with filling and/or a post. In a study by
Bragatto et al. [60], voxel size 0.200 mm was enough to
produce 100% accuracy while voxel size 0.250 mm resulted
in 90% accuracy, in the detection of vertical root fractures.
Parrone et al. [61] have recommended the 0.100 mm voxel
size (without an optimization filter) for root fracture detec-
tion in endodontically treated teeth. Even though individual
studies provide an insight, systematic reviews and meta-
analyses have revealed contradicting results concerning the
available evidence. A systematic review and meta-analysis
emphasizes the importance of adequate voxel size. Accord-
ing to the in vivo studies included in the study, CBCT has
a significantly higher sensitivity than periapical radiogra-
phy, particularly when a voxel size smaller than 0.2 mm is
used [62]. On the other hand, Ma et al. [27] conclude that
voxel size does not impact on the diagnostic accuracy of
root fracture in nonroot-filled teeth. The authors stated that
the diagnostic accuracy of root fractures in root-filled teeth
or teeth with posts still needs further investigation. Unfortu-
nately, both metal artifacts and artifact reduction algorithms
decrease the diagnostic accuracy of root fractures in CBCT
images [63]. Accordingly, the detection of vertical root frac-
tures is not only influenced by the type of imaging exami-
nation but also by the presence and type of the materials
used for the root canal treatment and restoration of the tooth
[64]. However, a systematic review on the impact of voxel
size in CBCT-based image acquisition has concluded that
no general protocol can be yet defined for CBCT examina-
tion of specific diagnostic tasks in dentistry, including the
detection of root fractures [65]. In addition, the actual spatial
resolution will always be considerably less than the physi-
cal voxel size as it is only one of the parameters that has an
impact on spatial resolution, where motion blur, scatter, the
two-dimensional detector and the three-dimensional recon-
struction process are among the others [27, 66].
Alveolar fracture, defined as a fracture of the alveolar pro-
cess, may involve the buccal or lingual cortical plates with
or without concomitant involvement of the alveolar socket,
and an associated root fracture may be present. If fracture
of a single cortical wall of the alveolar process is present,
it may be difficult to differentiate a root fracture from an
overlapping fracture line of the alveolar bone from intraoral
radiographs [7, 16].
CBCT is recommended for diagnosis of dentoalveolar
fractures as it has a higher diagnostic accuracy than con-
ventional radiographs [26, 41, 50, 54, 57, 67, 68]. Avsever
et al. [54] compared intraoral radiography and CBCT for
the detection of horizontal root fractures. They suggested
that CBCT should be considered as the most reliable imag-
ing modality for the diagnosis of horizontal root fracture.
Kajan and Taromsari [50] reported that the CBCT can be an
alternative in detection of root fractures with comparison of
the conventional periapical radiographs and CBCT images.
Figure 1 shows the panoramic radiograph and CBCT
images of a patient with two fractured teeth. The images
in cross-sectional planes reveal the orientation, extent and
number of fractures in detail. Figure 2a shows the labially
displaced cortical plate fracture on axial section. However,
detection of root fractures on CBCT is still a challenge
because of the streaking image artifacts from dense objects
such as root canal filling material, metal posts and brackets,
and lack of separation of fracture fragments. These artifacts
appear as streaks and dark bands due to the beam-hardening
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Fig. 1  a Cropped panoramic radiograph shows root fractures of the
right maxillary canine and first premolar tooth (circle); b pseudo-
panoramic view of CBCT image shows apical obliquely displaced
root fracture of the first premolar tooth (hollow arrow) and oblique
root fracture of the right maxillary canine tooth in the middle third of
the root (white arrow); c cross-sectional CBCT image demonstrates
oblique root fracture of the right maxillary first premolar in the mid-
Fig. 2  a Axial CBCT image shows labially displaced cortical plate fracture (arrow). b Cross-sectional CBCT images demonstrate alveolar frac-
ture (white arrow) and radiolucent artifact from metal brackets simulating a crown fracture (blue arrows)
effect and they mimic fracture lines [27, 41, 68]. Figure 2b
shows artifact resulting from metal brackets on cross-sec-
tional CBCT images.
CBCT in mandibular bone fractures
Classification of mandibular fractures according to the ana-
tomic region involves symphyseal–parasymphyseal, body,
angle and ramus fracture. Fractures affecting the ramus man-
dible are subdivided into the condylar or coronoid process
fractures [13].
Fractures are classified as to whether they are confined in
dental arc or involve the mandibular angle or the ascending
ramus [13]. The most common fracture sites in the mandible
are the condyle, body, and angle, followed less frequently
by the parasymphyseal region, ramus, coronoid process, and
alveolar crest [16].
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Oral Radiology
dle third of the root and labial displacement of the buccal root (hol-
low arrow) and two coronal horizontal fractures of the palatal root
of the right maxillary first premolar (white arrow); d cross-sectional
CBCT image demonstrates lateral luxation of the right maxillary
canine tooth with displacement of the root through the labial alveolar
bone accompanied by vertical root fracture (white arrow)
Panoramic radiography and conventional projection
imaging such as occlusal radiographs, transcranial, poster-
oanterior and submentovertex skull views, lateral oblique
views, form the baseline for the radiographic assessment
of patients with suspected mandibular fracture [7, 13, 16].
However, conventional projection radiograph is a two-
dimensional image of a three-dimensional object and these
techniques suffer from numerous limitations such as super-
imposition, blurring, and distortion of anatomical structures.
Three-dimensional imaging techniques such as CBCT are
able to generate images in sagittal, coronal and axial planes
and, three-dimensional reconstruction without superimpo-
sitions [5, 10–12, 14, 15, 20, 26]. Radiographic signs of
mandibular fracture include the presence of a radiolucent
line, a change in the normal anatomic outline or shape of
the structure, a defect in the outer cortical boundary and an
increase in the density of the bone, which may be caused by
the overlapping of two fragments of bone [16].
Oral Radiology
Fig. 3  Superimposition of cervical vertebrae obscures the symphy-
seal–parasymphyseal fracture and partial image obscures condyle
fracture on the panoramic radiograph because of incorrect patient
Fig. 4  a Three-dimensional reconstruction (upper left), sagit-
tal (upper right), coronal (lower left) and axial (lower right) images
showing a condylar fracture. Motion artifact is seen in the axial image
(lower right), resulting from patient movement during the scanning
procedure which appears as double contours of the left mandibular
ramus. b Cross-sectional images revealing the same condyle fracture.
CBCT has been reported to be superior to panoramic
radiography, especially in detecting condylar and coronoid
fractures and fractures in the anterior part of the mandible.
The mandibular condyle may be superimposed on panoramic
radiographs by the zygomatic process, maxillary tuberosity,
and the pterygoid process of the sphenoid bone [2, 20, 49].
Sirin et al. [14] compared the diagnostic accuracy of CBCT
and multislice CT in sheep mandibular condyle fractures.
They concluded that the accuracy of CBCT is similar to CT
positioning (image on the left). The fractures can be viewed on the
resultant pseudopanoramic view of CBCT (image on the right)
Upper row: the slice thickness is 5 mm, the slice interval is 0.4 mm.
The images are somewhat blurred due to the thick sections. Middle
row: the slice thickness is 0.4 mm, the slice interval is 5.1 mm. The
condyle cannot be viewed in all sections as the slice interval is too
thick. Bottom row: the slice thickness is 0.4 mm, the slice interval is
0.4 mm. The condyle and the fracture line can be seen in detail
in the diagnosis of fractures. Choudhary et al. [19] assessed
the diagnostic quality of CBCT images and compared them
with conventional images from patients with maxillofacial
trauma. They stated that the detection of fracture lines on
the midface and mandibular condylar region is significantly
enhanced using CBCT when compared with conventional
radiographs. In a study investigating the diagnostic effi-
cacy of CBCT for mandibular fractures, it has been shown
that CBCT provides more accurate information than the
13

Fig. 5  a Figure shows the CBCT images of the case shown in Fig. 3.
Symphyseal–parasymphyseal fracture is not clearly seen on the pseu-
dopanoramic CBCT view when the image layer is 25  mm wide, as
shown in the axial image. b Figure shows the CBCT images of the
case shown in Fig. 3. Symphyseal–parasymphyseal fracture is clearly
seen on the pseudopanoramic CBCT view when the image layer is
panoramic radiographs in patients with suspected mandibu-
lar fracture [20]. Figure 3 shows that the fracture line in the
symphyseal–parasymphyseal region and the condyle can be
viewed on the pseudopanoramic view whereas these not be
evaluated accurately on the panoramic radiograph.
For suspected fractures of the mandible, either CBCT or
CT imaging is the modality of choice for imaging mandibu-
lar trauma, because of the similar properties for the evalu-
ation of bony components and providing adequate three-
dimensional hard tissue information. However, CBCT has
a limitation of not being able to show the soft tissue differ-
entiation. When the soft tissue injury to the temporoman-
dibular joint capsule or articular disk is suspected, magnetic
resonance imaging should be considered to provide soft tis-
sue visualisation [5, 16].
CBCT data can be reformatted, and several different types
of images in oblique or curved image planes can be synthe-
sized, in addition to the images in the orthogonal planes and
three-dimensional reconstructions. The slice thickness of the
sectional images and slice interval can be defined (Fig. 4).
In addition, selecting multiple nodes along the centerline
corresponding to the jaw arch on an appropriate axial image
automatically draws a planning line, and creates a “simu-
lated” or “pseudopanoramic” image that is useful for jaw
evaluation. The thickness of the pseudopanoramic image is
important to visualize the anatomical structures and to avoid
missing disease (Fig. 5) [69, 70].
13
Oral Radiology
6 mm wide, as shown in the axial image. c When the planning line is
drawn at the level of the dental arch (image on the right), the fracture
line cannot be viewed on the resultant pseudopanoramic view (image
on the left). d When the planning line is drawn at the level of mandib-
ular body (image on the right), the fracture line can clearly be viewed
on the resultant pseudopanoramic view (image on the left)
Conclusion
Radiographic examination is an essential part of the diag-
nosis and treatment planning in dentomaxillofacial trauma.
Radiographic imaging of the traumatized patients should
comply with the ALADA principle, and the imaging meth-
ods should be selected according to the type and severity of
the injury. The beneficial role of the CBCT imaging in den-
tomaxillofacial trauma has been studied with various clinical
applications in this review. Even though CBCT is providing
increased opportunities for three-dimensional imaging of the
maxillofacial region, it will be developed by studies that
make it more useful in clinical practice.
Compliance with ethical standards 
Conflict of interest  All the authors declare that they have no conflict
of interest.
Human rights statement  All procedures followed were in accordance
with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki
Declaration of 1964 and later versions.
Informed consent  Informed consent was obtained from all patients for
being included in the study.
Oral Radiology

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