Clinical Research
A Comparison of 2- and 3-dimensional Healing
Assessment after Endodontic Surgery Using
Cone-beam Computed Tomographic Volumes or
Periapical Radiographs
Tom Schloss, DMD, MSc,*† David Sonntag, DMD, PhD,‡ Meetu R. Kohli, BS, DMD,†
and Frank C. Setzer, DMD, PhD, MS†
Abstract
Introduction: The aim of this study was to compare the
assessment of healing after endodontic microsurgery us-
ing 2-dimensional (2D) periapical films versus 3-
dimensional (3D) cone-beam computed tomographic
(CBCT) imaging. Methods: The healing of 51 teeth
from 44 patients was evaluated using Molven’s criteria
(2D) and modified PENN 3D criteria. The absolute area
(2D) and volume (3D) changes of apical lesions preoper-
atively and at follow-up were calculated by segmenta-
tion using OsiriX software (Pixmeo, Bernex,
E ndodontic microsurgery
Switzerland) and ITK-Snap (free software). Results:
There was a significant difference between the mean
preoperative lesion volumes of 95.34 mm3 (n = 51,
standard deviation [SD] 196.28 mm3) versus
6.48 mm3 (n = 51, SD 17.70 mm3) at follow-up
(P < .05). The mean volume reduction was 83.7%. Pre-
operatively, mean lesion areas on periapical films were
13.55 mm2 (n = 51, SD 18.80 mm2) and 1.83 mm2
(n = 51, SD .68 mm2) at follow-up (P < .05). Accord-
ing to Molven’s criteria, 40 teeth were classified as com-
plete healing, 7 as incomplete healing, and 4 as
uncertain healing. Based on the modified PENN 3D
criteria, 33 teeth were classified as complete healing,
14 as limited healing, 1 as uncertain healing, and 3 as
unsatisfactory healing. The variation in the distribution
of the 2D and 3D healing classifications was significantly
different (P < .05). Periapical healing statuses incom-
plete healing or uncertain healing according to Molven’s
criteria could be clearly classified using 3D criteria. Con-
clusions: CBCT analysis allowed a more precise evalua-
tion of periapical lesions and healing of endodontic
microsurgery than periapical films. Significant differ-
ences existed between the 2 methods. Over the observa-
tion period, the mean periapical lesion sizes significantly
decreased in volume. Given the correct indications, the
From the *Private Practice, Nuremberg, Germany; †Department of Endodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
and ‡Poliklinik fuer Zahnerhaltung, Parodontologie und Endodontologie, Heinrich-Heine-Universitaet Duesseldorf, Duesseldorf, Germany.
Address requests for reprints to Dr Frank C. Setzer, School of Dental Medicine, University of Pennsylvania, 240 S 40th Street, Philadelphia, PA 19104. E-mail address:
fsetzer@upenn.edu
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.02.007
1072 Schloss et al.
use of CBCT imaging may be a valuable tool for the evaluation of healing of endodontic
surgery. (J Endod 2017;43:1072–1079)
Key Words
Apicoectomy, cone-beam computed tomography, endodontic, healing, microsurgery,
outcome, root-end surgery, success
uses high-magnification,
ultrasonic root-end prepa-
Significance
CBCT evaluation allowed for a precise volumetric
analysis of preoperative periapical lesions and the
ration and biocompatible
assessment of healing after endodontic microsur-
root-end filling materials.
Success rates in the range gery. Healing classification in 3D (CBCT) analysis
of 90% have been reported was significantly different from 2D (periapical radi-
for endodontic lesions ography) analysis.
(1, 2). Most original
studies used Molven’s criteria for the assessment of healing after endodontic
surgery, including potential clinical symptoms and radiographic healing based on
periapical radiographs.
Cone-beam computed tomographic (CBCT) imaging is a widely accepted tool for
diagnostic evaluation in dentistry. However, its main limitation is radiation exposure.
Indications in endodontics include the detection of periapical lesions, fractures, or per-
forations; the evaluation of complex root anatomy, existing root fillings, and the location
of separated instruments; surgical treatment planning; and the diagnosis of traumatic
injuries to teeth or the alveolar bone (3, 4). In surgical treatment planning, CBCT
imaging is helpful to assess the extent and location of apical periodontitis; the bone
thickness over pathologic defects; and the proximity to anatomic structures such as
the mental nerve, sinus cavity, or adjacent teeth.
Studies have shown that CBCT imaging is superior for the detection of apical
periodontitis when compared with periapical radiographs (5–7). The risk-benefit
ratio in terms of radiation exposure outweighs the use of CBCT imaging for regular
follow-ups after endodontic procedures unless the stage of healing is difficult to
discern. Few studies compared 2-dimensional (2D) and 3-dimensional (3D) healing
for primary endodontic treatment (8, 9) or endodontic surgery (10–12). No
investigation compared the outcome assessment for endodontic microsurgery
JOE — Volume 43, Number 7, July 2017

derived from either 2D or 3D imaging taking into account planar as
well as volumetric changes with or without the use of predefined 3D
healing criteria.
The aim of the present study was to compare the assessment of
healing after endodontic microsurgery using periapical films (2D)
and CBCT (3D) imaging. The evaluation was based on cases in which
both a periapical radiograph and a CBCT volume were available after
at least 1 year of follow-up. The study investigated 2 hypotheses. The
first hypothesis suggested that there would be no differences in
outcome classifications derived from the assessment of 2D periapical
films and 3D CBCT images after at least 1 year of follow-up. The sec-
ond hypothesis stated that if a healing assessment was inconclusive
by means of periapical radiography, it would also be inconclusive us-
ing CBCT imaging.
Materials and Methods
All cases subjected to the 2D versus 3D analysis comparison were
from a subpopulation of patients who had received endodontic micro-
surgery by a single operator (T.S.) between 2011 and 2013. CBCT scans
had been taken preoperatively and at least 1 year after surgery. Because
CBCT imaging is subject to the ‘‘as low as reasonably achievable’’ prin-
ciple, only selected patients had received a 3D scan at follow-up. Briefly,
these indications included the clarification of healing patterns at follow-
up and the diagnostic evaluation of symptoms to determine odontogenic
versus nonodontogenic causes.
The inclusion criteria were
1. A history of primary endodontic microsurgery (no resurgeries)
2. Radiologically and clinically intact restoration at follow-up (exclu-
sion of reinfection by coronal microleakage)
3. Compliance of CBCT scans with as low as reasonably achievable
principles and indications following local guidelines for appropriate
CBCT use (4) as described previously
The exclusion criteria were as follows:
1. Patients with a history of systemic disease, such as anemia, diabetes
mellitus, metabolic disease, arteriosclerosis, or liver or kidney dis-
ease; a compromised immune response; a history of radiation in the
head/neck area; a history of cancer treatment; a history of heavy
smoking (World Health Organization); or a history of medication
with bisphosphonates, steroids, or cytostatics
2. Teeth with an earlier history of endodontic surgery (apicoectomy,
root-end surgery, root amputations, or bi- or trisections)
3. Teeth with root fractures or iatrogenic perforations
4. Teeth with apicomarginal defects, periodontal probing depths
>4 mm, and/or increased mobility (II/III) (classes D–F according
to Kim and Kratchman (13) [impaired volume analysis])
5. Endodontic surgery with the use of bone grafting or barrier mate-
rials (impaired volume analysis)
Endodontic Microsurgery
Treatment Planning. All patients had a consultation appointment
for the collection of diagnostic information (including acquisition of a
preoperative CBCT volume) as well as a thorough review of the surgical
protocol, potential complications, and postoperative and follow-up
procedures.
Surgical Procedures. The surgery was performed using modern
microsurgical techniques in a consistent manner in all patients,
including high-magnification, ultrasonic root-end preparation and
root-end fillings with mineral trioxide aggregate.
JOE — Volume 43, Number 7, July 2017
Clinical Research
Radiography
Acquisition and Clinical Evaluation. All periapical films were
obtained with the parallel technique using a film holder (Dentsply Rinn,
Elgin, IL) and an x-ray tube (Sirona Dental GmbH, Walls bei Salzburg,
Austria) at 60 kV and 7 mA and intervals ranging from 0.08 to 0.18 sec-
onds depending on the area and regional bone density using a XIOS
PLUS sensor (Sirona Dental GmbH) and SIDEXIS XG software (Sirona
Dental GmbH). CBCT images were obtained using the Veraviewepocs
3De CBCT machine (J Morita Mfg Corp, Kyoto, Japan) using a limited
field of view (40  40 mm) at a 9.4-second duration for a 180 rotation
at 80 kV and 5.0–8.0 mA and a voxel size of 0.125 mm. All CBCT vol-
umes were analyzed using i-Dixel 2.0 software (J Morita Mfg Corp) and
reconstructed at a slice thickness and intervals of 0.125 mm.
Healing Evaluation. Molven’s criteria were used for the 2D assess-
ment for the purposes of this study (14–16). All preoperative and
follow-up radiographs were evaluated independently from the CBCT
volumes and blinded and randomized by 2 faculty members of an Amer-
ican Dental Association–accredited endodontic specialty program with
long-term experience in the evaluation of surgical healing in endodon-
tics (F.S. and M.K.). Both evaluators were calibrated and reviewed the
radiographs under standardized conditions. Magnification tools could
be used if necessary. After evaluation, scores were reviewed, a kappa
value for agreement was calculated, and situations with differing opin-
ions were resolved by discussion until an agreement was reached. Out-
comes were classified as complete healing and incomplete healing
(dichotomized as success) or uncertain healing and unsatisfactory
healing (dichotomized as failure) following Molven’s criteria.
Modified PENN 3D criteria were used for the evaluation of surgical
endodontic healing by CBCT imaging (Fig. 1) (17). Similar to the
assessment of 2D healing as outlined earlier, 3D healing was assessed
by 2 examiners (T.S. and F.S.), and any disagreement was resolved by
discussion until a final agreement was reached. Outcomes were classi-
fied as complete healing and limited healing (dichotomized as success)
or uncertain healing and unsatisfactory healing (dichotomized as fail-
ure).
Lesion Area and Volume Calculation. Both 2D and 3D lesion
calculation was performed using ITK-SNAP (free software under the
GNU General Public License developed by the National Institutes of
Health, the US National Institute of Biomedical Imaging and BioEngi-
neering, the US National Library of Medicine, the Universities of Penn-
sylvania and North Carolina, and an independent developer group). For
2D images, the software allowed for a straightforward assessment of the
periapical defect size preoperatively and at follow-up using a grayscale
color identification module. The area of the defect was then expressed
as a percentage of the total area of the digital image, a standard size for
all periapical images taken with the XIOS PLUS sensor. After calculation
of the proportional relationship of the defect size compared with the to-
tal area of the digital image, the defect size area was expressed as the
number of pixels and converted to mm2 (Fig. 2). If a multirooted tooth
had more than 1 periapical lesion, the individual defect areas were
calculated and then added together to get a total defect area.
The 3D volumes preoperatively and at follow-up were similarly
calculated using ITK-SNAP (Figs. 3–5). However, the complexity of a
3D defect around the root tips required additional steps of rendering,
manual correction, and translation. Defect area segmentation and
volume calculation were performed using the volumes at highest
resolution (slice thickness and intervals = 0.125 mm) in a Digital
Imaging and Communication in Medicine 3 Format exported from i-
Dixel 2.0. The Digital Imaging and Communication in Medicine
images were then converted into the Neuroimaging Informatics
Technology Initiative format, processed anonymously, and
2D and 3D Healing Assessment after Endodontic Surgery 1073
Clinical Research
Figure 1. Modified Penn 3D criteria (radiographic).
randomized in ITK-SNAP using a semiautomatic segmentation algorithm
sequence (18). Briefly, ITK-SNAP allowed for a simultaneous represen-
tation of the sagittal, axial, and coronal views. The periradicular defects
were selected as subregions using a grayscale value range selection tool
after reading the grayscale values of the defects. These defect and
volume-specific grayscale values were individually selected to allow
for semiautomatic defect volume recognition and calculation using auto-
mated spherical fillers (‘‘bubbles’’) that populated the defect in repeated
runs until the defect volume was completely filled. If necessary, a manual
correction was applied at this stage of the defect volume measurements,
1074 Schloss et al.
allowing for additions and/or subtractions as small as individual voxels
(eg, in areas where foreign body materials prevented the automatic seg-
mentation from working correctly). The Neuroimaging Informatics
Technology Initiative allowed for direct expression of the number of vox-
els and conversion into mm3. If a multirooted tooth had more than 1
periapical lesion, the individual defect volumes were added together.
All cases included in the study had teeth with an original defect at least
twice the width of the periodontal ligament (6, 7, 19–21). For follow-up,
any radiolucent volumes with less than twice the width of the periodontal
ligament were counted as a 0-mm3 defect size and considered healed.
JOE — Volume 43, Number 7, July 2017

Figure 2. Manual 2-dimensional segmentation of a periapical defect on a maxillary left first molar. (A) A radiograph imported into ITK-SNAP software. (B) Eval-
uation of lesion area by manual drawing.
Statistical Analysis
The nonparametric Wilcoxon signed rank test, paired and un-
paired t tests, and analysis of variance tests were applied using SPSS
v.20 (SPSS/IBM, Armonk, NY).
Results
Between 2011 and 2013, a total of 385 patients received endodon-
tic microsurgery by the first author. Of these, a subpopulation of 44 pa-
tients had CBCT scans taken at a follow-up appointment, including 51
teeth that complied with the inclusion/exclusion criteria. For 13 teeth,
the scans were taken by the first author (T.S.) to ascertain the stage of
periapical healing. An additional 5 teeth with conclusive healing
JOE — Volume 43, Number 7, July 2017
Clinical Research
patterns were part of these scans. CBCT images of 33 teeth were ac-
quired to rule out any odontogenic involvement in which symptoms
associated with sinusitis, temporomandibular or occlusal dysfunctions,
or marginal gingivitis had been diagnosed.
Of 44 patients, 18 were men and 26 were women with a mean age
of 45.9 years. A total of 80 roots underwent surgery. There were 23 teeth
in the mandible and 28 in the maxilla, including 11 anteriors, 11 pre-
molars, and 29 molars. Twenty periapical lesions were located on a sin-
gle root, 12 teeth had separate lesions on 2 roots, and 19 teeth had
combined lesions affecting more than 1 root. Twenty-three teeth had
received surgery on 1 root, 27 on 2 roots, and 1 tooth on 3 roots.
The mean follow-up period was 23.7 months, ranging from 12 to
37 months.
2D and 3D Healing Assessment after Endodontic Surgery 1075
Clinical Research
Figure 3. ITK-SNAP program surface for segmentation of 3D lesions.
Healing Assessment with 2D Radiographs
Randomized blinded evaluation resulted in 40 teeth being classified
as complete healing, 7 teeth as incomplete healing, and 4 teeth as uncer-
tain healing (47/51 [92.2%] successful healing) according to Molven’s
criteria. The kappa value for the initial agreement was 90.2%; 5 cases
were resolved by discussion (F.S. and M.K.). The mean area size
measured on the periapical radiographs was 13.55 mm2 (n = 51, stan-
dard deviation [SD] 18.80 mm2) preoperatively and 1.83 mm2
Figure 4. Initiation of the semiautomatic segmentation algorithm.
1076 Schloss et al.
(n = 51, mean = 1.83 mm2) at follow-up. This reduction in lesion
size was statistically significant (P < .05, paired t test).
Healing Assessment with 3D CBCT Volumes
The outcome assessment based on 3D analysis resulted in 33 teeth
being classified as complete healing, 14 teeth as limited healing, 1 tooth
as uncertain healing, and 3 teeth as unsatisfactory healing according to
the modified PENN 3D criteria (47/51 [92.2%] successful healing). The
JOE — Volume 43, Number 7, July 2017

Figure 5. Completed segmentation of a lesion associated with the maxillary premolar.
kappa value for the initial agreement was 88.2%; 6 cases were resolved
by discussion (F.S. and T.S.). Preoperatively, the mean absolute lesion
volume was 95.34 mm3 (n = 51, SD 196.28 mm3) and 6.48 mm3
(n = 51, SD 17.70 mm3) at follow-up. This change in the mean vol-
ume was statistically significant (P < .05, paired t test). Multiple lesions
per tooth or combined lesions were evaluated as a single volume. Pre-
operatively, the absolute largest volume was 654.1 mm3; the smallest
was 1.5 mm3. The mean reduction was 83.7%. For 38 teeth, the volume
reduction was 100%; for 7 cases, it was >90%; for 2 cases, it was <90%,
and for 4 cases, it was <0% (increase of lesion volume). There was a
statistical correlation between the 3D criteria and volume reduction
(P < .05, analysis of variance; uncertain healing and unsatisfactory heal-
ing were grouped because of the small sample size).
Comparison of 2D and 3D Healing
Scores were assigned to the individual 2D and 3D healing cate-
gories (1 for complete healing [2D/3D], 2 for incomplete healing
[2D] and limited healing [3D], 3 for uncertain healing [2D/3D], and
4 for unsatisfactory healing [2D/3D]) and compared using the paired
nonparametric Wilcoxon signed rank test. The overall mean score for
2D healing was 1.29 (n = 51, SD 0.61) and 1.49 (n = 51,
SD 0.81) for 3D healing; when dichotomized for success and failure,
it was 1.15 (2D) (n = 47, SD 0.36) and 1.30 (3D) (n = 47,
SD 0.46) and 3.0 (2D) (n = 4, SD 0.0) and 3.75 (3D) (n = 4,
SD 0.5), respectively. The distribution of the healing categories be-
tween 2D and 3D analysis was significantly different (z = 1.8,
P < .05). The mean lesion reduction on periapical radiographs versus
that assessed on CBCT volumes was compared indirectly. The square
roots of the preoperative to follow-up area reduction (2D) (n = 51,
mean = 2.33 mm, SD 2.77 mm) were compared with the cubic roots
of the preoperative to follow-up volume reduction (3D) (n = 51, mean
= 3.14 mm, SD 2.40 mm), which was significantly different (P < .05,
paired t test). Therefore, the first hypothesis that there would be no dif-
ferences in the outcome classifications derived from the assessment of
JOE — Volume 43, Number 7, July 2017
Clinical Research
2D periapical films and the 3D CBCT images after at least 1 year of
follow-up was rejected.
3D Evaluation of Nonconclusive Healing Patterns
The initial healing evaluation was performed by using periapical
radiographs (T.S.); however, for 13 teeth, the healing pattern was
inconclusive, and CBCT volumes were taken. The retrospective 2D eval-
uation for this investigation using Molven’s criteria (F.S. and M.K.) clas-
sified 2 of these teeth as complete healing, 7 as incomplete healing, and
4 as uncertain healing. CBCT analysis allowed for all of these teeth to be
placed into the 3D healing categories of the modified PENN 3D criteria
(T.S.and F.S.). One tooth each was classified as 1A, 1D, and 3A; 2 teeth
each as 2A, 2D, and 4; and 4 teeth as 2B. Based on these results, the
second hypothesis that if healing assessment was inconclusive with a
periapical radiograph, it would also be inconclusive using CBCT imag-
ing was rejected.
Discussion
Endodontic surgery requires regular follow-up to evaluate the
healing process. A 1-year follow-up is commonly accepted as a good
indication for the final outcome (22, 23). Thus, a mean follow-up
period of 23.7 months was deemed sufficient for an adequate analysis
of 2D versus 3D assessment.
CBCT volumes were taken with the Veraviewepocs 3De CBCT ma-
chine, providing a voxel size of 125 mm in the limited field of view mode
at a setting providing 40% less irradiation compared with standard pro-
gramming. This resulted in an effective dose of 19–44 mSv compared
with single digital radiographs in which it may range between 0.6 and
5.0 mSv (24). The increased radiation exposure of CBCT imaging
limited the available sample size compared with the overall number
of patients who had received surgery between 2011 and 2013. Thus,
the overall distribution of successful versus failed cases may not be
representative for the overall population, and as a result the
2D and 3D Healing Assessment after Endodontic Surgery 1077
Clinical Research
dichotomized ratio of successful versus failed cases was not reported as
an outcome rate.
The primary reasons for CBCT acquisition were assessment of
inconclusive healing and evaluation of odontogenic versus nonodonto-
genic symptoms. Although possibly not representative for the overall
population, this subpopulation allowed for the investigation of the 2
central hypotheses (ie, that there were no differences in outcome clas-
sifications based on 2D periapical films versus 3D CBCT images and that
inconclusive healing assessment would not be different between 2D and
3D imaging). According to Friedman (25), incomplete healing versus
uncertain healing could be easily misinterpreted using Molven’s
criteria. Indeed, 11 teeth included in the initial sample of 13 CBCT im-
ages taken for inconclusive healing patterns fell into the categories
incomplete healing or uncertain healing based on the 2D Molven clas-
sification for this study. Furthermore, 3D evaluation revealed that most
difficulties in assessment were related to the summation effect of oral
radiographs, including overprojection of the incisive or mental
foramina, zygomatic arch, or linea mylohyoidea, which is in agreement
with previous studies (21, 26–28). CBCT evaluation allowed for a
precise evaluation of all related cases, which is in accordance with
findings that showed good repeatability and reproducibility for CBCT
evaluation of healing after apical surgery (29).
The quality of the 3D segmentation depended on various factors,
such as device-specific parameters, settings and stability, artifacts, and
homogeneity of the density of the object. The precision of CBCT 3D seg-
mentation was verified by in vitro investigation of artificial periapical
bone defects (30). However, there is a difference between artificial,
clearly limited defects and random borders of an in vivo pathologic
bone defect, which explains the need for manual corrections
throughout the segmentation process. Although CBCT imaging may
have limitations in regard to accurately representing smaller defects,
digital periapical radiography was shown to be even less accurate
(31). Because most studies define a periapical defect to be at least twice
the width of a healthy periodontal ligament space, it can be assumed that
periapical defects were correctly identified in this study (6, 7, 19–21).
Because the study was retrospective, no standardized radiographs were
taken. This may lead to slight angulation changes; however, all
radiographs were taken with the same sensor, software, and film
holder by the same operator, limiting the variability.
Preoperative radiographs and volumes were compared with follow-
up periapical films and CBCT images. No CBCT volumes were taken
immediately after the surgical intervention because of radiation con-
cerns, so the results of this study reflect the absolute changes from before
endodontic surgery until follow-up, with a mean reduction in lesion vol-
ume from 95.34 mm3 (preoperatively) to 6.48 mm3 (at follow-up). The
percentage of volume reduction calculated after segmentation showed a
statistical correlation with the 3D criteria. Analogue to the Molven
criteria, the worst score of any root was representative for the tooth
for 3D analysis. Although 38 cases showed a 100% volume reduction,
only 33 teeth were classified as complete healing in 3D analysis. In total,
an equal number of cases were classified as successful or failed after
blinded and randomized evaluation for both 2D and 3D imaging because
of the dichotomized grouping of complete healing (1) and incomplete/
limited healing (2) for success and uncertain healing (3) and unsatis-
factory healing (4) for failure. However, some cases evaluated as com-
plete healing (1) based on Molven’s criteria were reclassified as limited
healing (2) using CBCT imaging, and uncertain healing (3) cases based
on Molven’s criteria were changed to unsatisfactory healing (4) using 3D
criteria. For example, 5 maxillary molars that healed with intact lamina
dura and periodontal ligament covering the resected root surface but
demonstrated a physiologic fenestration or a thin, undetectable buccal
plate received the 3D criteria classification ‘‘2D.’’
1078 Schloss et al.
The difference in assessment between 2D and 3D evaluation was
statistically significant. Aggregating the scores assigned for statistical
evaluation, complete healing (1), incomplete/limited healing (2), un-
certain healing (3), and unsatisfactory healing (4) resulted in a sum
of 66 for the 2D criteria and 76 for the 3D criteria evaluation, demon-
strating a trend for a worse outcome with 3D evaluation. Together with
the statistically significant differences in lesion area (2D) versus lesion
volume (3D) reduction, this led to the rejection of the first hypothesis.
This is in agreement with von Arx et al (12), who described worse sit-
uations for about one third of cases evaluated, but in disagreement with
Christiansen et al (10), and Tanomaru-Filho et al (11), who found no
differences in radiographic healing assessment. However, these studies
compared planar changes of lesion sizes on periapical radiographs with
selected sagittal and/or coronal views in CBCT volumes and not volu-
metric changes.
The use of square roots of lesion areas and cubic roots of lesion
volumes allowed for an objective comparison of the assessment of
lesion changes. Clinically, a 2D lesion area addresses the mesiodistal
and apicocoronal extent of the defect. The result that mean cubic roots
derived from the CBCT volumes were significantly larger than mean
square roots derived from the periapical radiographs demonstrated
that buccolingual directions on average had the largest extent of a peri-
radicular defect. This finding implies that, when clinically relying on
periapical radiographs, the buccolingual extent of a defect is not only
the unknown dimension but also the largest of the 3 dimensions.
As of today, increased radiation doses administered by CBCT im-
aging limit its use for regular follow-up for endodontic surgery. It
should only be considered if appropriate. However, if radiation intensity
can be minimized by improved hardware and/or software algorithms,
this study may suggest its use for follow-up of endodontic microsurgery
because of its superior accuracy compared with periapical radiographs.
Conclusion
CBCT imaging allowed a more precise evaluation of periapical le-
sions and healing than periapical films. Significant differences existed
between the 2 methods. Over the observation period, the periapical le-
sions significantly decreased in volume. Given the correct indications,
the use of CBCT imaging is recommended as a valuable tool for end-
odontic microsurgery.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Clinical Research
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