Volume 88 • Number 10

Cone-Beam Computed Tomography and

Interdisciplinary Dentofacial Therapy: An
American Academy of Periodontology
Best Evidence Review Focusing on Risk
Assessment of the Dentoalveolar Bone
Changes Influenced by Tooth Movement
George A. Mandelaris,*† Rodrigo Neiva,‡ and Leandro Chambrone§i¶

Background: The aim of this systematic review is to evaluate whether cone-beam computed tomog-
raphy (CBCT) imaging can be used to assess dentoalveolar anatomy critical to the periodontist when
determining risk assessment for patients undergoing orthodontic therapy using fixed or removable
appliances.
Methods: Both observational and interventional trials reporting on the use of CBCT imaging assessing
the impact of orthodontic/dentofacial orthopedic treatment on periodontal tissues (i.e., alveolar bone)
were included. Changes in the alveolar bone thickness and height around natural teeth as well as treat-
ment costs were evaluated. MEDLINE (via PubMed) and EMBASE databases were searched for articles
published in the English language, up to and including July 2016, and extracted data were organized into
evidence tables.
Results: Thirteen studies were included in this systematic review describing the positive or deleterious
changes on the alveolar bone surrounding natural teeth undergoing orthodontic tooth movement or influ-
enced by orthopedic forces through fixed appliances. Clinical recommendation summaries presenting the
strengths and weaknesses of the evidence in terms of benefits and harms were generated.
Conclusions: CBCT imaging can improve the periodontal diagnostic acumen regarding alveolar bone
alterations influenced by orthodontic tooth movement and can help determine risk assessment prior to
such intervention. Clinicians are also better informed to determine risk assessment and develop preven-
tative or plan interceptive periodontal augmentation (soft tissue and/or bone augmentation) therapies for
patients undergoing orthodontic tooth movement. These considerations are recognized as being espe-
cially critical for treatment approaches in patients where buccal tooth movement (expansion) is planned
in the anterior mandible or involving the maxillary premolars. J Periodontol 2017;88:960-977.
KEY WORDS
Alveolar bone; cone-beam computed tomography; evidence-based dentistry; imaging, three-dimensional;
periodontics; tooth movement techniques; surgical procedures, operative.

* Private practice, Oakbrook Terrace, Park Ridge, and Chicago, IL.

† Department of Graduate Periodontics, University of Illinois College of Dentistry, Chicago, IL.
‡ Department of Graduate Periodontics, College of Dentistry, University of Florida, Gainesville, FL.
§ Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia.
i School of Dentistry, Ibirapuera University (Unib), São Paulo, SP, Brazil.
¶ Department of Periodontics, College of Dentistry, The University of Iowa, Iowa City, IA.

doi: 10.1902/jop.2017.160781

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J Periodontol • October 2017
C
one-beam computed tomography (CBCT) in
periodontology has primarily been used for
diagnostic inquiry of regional anatomy and
vital structure identification in dental implant treat-
ment.1-6 Historically, treatment planning decisions
and risk assessment specific to alveolar bone of the
natural dentition in patients requiring orthodontic
tooth movement has been either intuitive and sub-
jectively measured or determined from clinical in-
formation and two-dimensional (2D) radiographic
analyses.7,8 Unequivocally, studies have confirmed
that three-dimensional (3D) imaging allows for su-
perior measurement accuracy of alveolar ridge height
and width, a known limitation of intraoral periapical
or panoramic radiographs.1-6 It is well recognized that
traditional 2D imaging diagnostics do not allow for
meaningful dentoalveolar bone risk assessment,
namely of the buccal plate, prior to orthodontic tooth
movement.7,8 Only recently7,8 has 3D CBCT imaging
been considered to have diagnostic merit in providing
risk assessment of alveolar bone loss (ABL) produced
from tooth movement and in improving the compre-
hensive diagnostic process of interdisciplinary dento-
facial therapy (IDT) for the craniomandibular system.
The true impact of advanced imaging as related
to diagnosis, decision-making, and risk assessment
when applied to a more global, and often complex,
treatment-planning context has yet to be realized.
By definition, IDT is demanding and often involves
management of a compromised natural dentition.
Because of the nature and scope of such cases, it is
not uncommon for multiple disciplines to be involved
to achieve a collaboratively based plan that is cen-
tered on preservation of the natural dentition. The
specific focus question of this American Academy of
Periodontology (AAP) Best Evidence Consensus
(BEC) paper addresses alterations of dentoalveolar
bone associated with orthodontic tooth movement
using CBCT technology. This has been a topic given
little attention or study relative to other advanced
imaging applications. Such alterations were pre-
viously unrecognized and/or underappreciated by
clinical examination and/or 2D analysis.7,8 Tradi-
tional orthodontic radiographs lack the ability to
capture hard tissue changes occurring during tooth
movement. The advent of 3D imaging has now led to
the interpretation of anatomic reality prior to or fol-
lowing intervention. CBCT imaging has become
a clarion call for re-evaluating treatment approaches,
especially in patients undergoing more comprehen-
sive care and where the integration of multiple dis-
ciplines of dentistry are required. As a result of more
astute preoperative imaging assessment and plan-
ning capabilities now available, alveolar bone alter-
ations secondary to tooth movement have surfaced
as one of the most important issues for pre-
Mandelaris, Neiva, Chambrone
intervention periodontal diagnosis and treatment
planning. Approximately 12% of maxillary central
incisors may present with a complete lack of facial
bone (dehiscence or fenestration) despite not suf-
fering attachment loss (AL).9 In the presence of
malocclusions (namely proclined anterior teeth), the
frequency of fenestrations and dehiscences as as-
sessed by CBCT has been reported to increase to
approximately 35% and 50%, respectively, especially
in the anterior region of the mandible.10,11 It has been
suggested that orthodontic tooth movement in the
presence of a thin alveolar housing may result in the
development of dehiscences and/or fenestrations.10,11
This may predispose teeth to the formation of plaque-
induced (i.e., periodontitis) and non-plaque-induced
gingival lesions (i.e., gingival recessions), often but not
always associated with increased tooth mobility post-
treatment.12-14 It is also well recognized that, in general,
CBCT imaging tends to overestimate the presence or
absence of thin facial bone when compared to direct
measurements.15 Nonetheless, these common ana-
tomic conditions may negatively affect the patient’s
periodontal phenotype (especially anterior mandibular
teeth), and as a result, require surgery by way of soft
tissue and/or bone augmentation/guided periodontal
tissue regeneration to prevent or manage deleterious
sequelae as a result of tooth movement.16
It is widely understood and accepted that orthodontic
tooth movement is limited by the dentoalveolar ana-
tomic boundaries that are set by the cortical plates of
the alveolus at the level of the incisor apices. These
boundaries are often referred to as the ‘‘orthodontic
walls’’ within which tooth movement must occur to limit
the influence of tooth movement on the occurrence of
iatrogenic sequelae.17 The 2014 AAP Regeneration
World Workshop systematic review reports that ‘‘the
direction of the tooth movement and the bucco-lingual
thickness of the gingiva play important roles in soft
tissue alterations during orthodontic treatment.’’18 It
was reported that ‘‘thick periodontal phenotypes may
help to prevent either development or recurrence of
recession compared to thin phenotypes.’’19
When evaluating alveolar bone dimensions using
3D CBCT analysis or clinical inspection, normal
human anatomy often demonstrates deficiencies in
dentoalveolar bone volume. The dentoalveolar bone
compartment refers to the volumetric relationship of
the alveolar bone to the tooth root. Deficiencies in
dentoalveolar bone are represented anatomically
(direct measurement/intrasurgical observation) as
fenestrations and/or dehiscences that may or may
not manifest clinically in recession-based AL. Den-
toalveolar bone deficiencies are also common when
arch length limitations are present, commonly mani-
festing as dental crowding. Deficiencies in dentoal-
veolar bone volume may or may not be present in
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CBCT and Interdisciplinary Dentofacial Therapy
conjunction with an underlying skeletal malocclusion.
Skeletal malocclusions represent a mismatch or dis-
crepancy between the skeletal bases, while alveo-
loskeletal malocclusions represent a discrepancy
between the dentoalveolar compartment and the
skeletal base.20
Mandelaris et al.21 have published a classification
system of dentoalveolar bone phenotypes using CBCT
imaging to help provide risk assessment prior to or-
thodontic intervention. Cross-sectional evaluation of
dentoalveolar bone is compartmentalized into either
crestal or radicular zones, and facial bone thickness is
classified as either thick or thin using published av-
erages of known facial bone anatomy/thickness.
Richman22 proposed a similar risk assessment mo-
dality using CBCT imaging to determine alveolar bone
support relative to tooth size and/or position. More
recently, facial vertical skeletal patterns have also
shown correlations between malocclusion and alveolar
bone thickness.23
This BEC paper aims to evaluate whether CBCT
imaging can be used to assess dentoalveolar re-
lationships critical to determining risk assessment
and help determine and improve periodontal treat-
ment needs in patients undergoing orthodontic
therapy. To help determine an answer, the following
specific focused question was addressed: Does
CBCT imaging improve diagnostic acumen and
influence periodontal decision making in patients
undergoing tooth movement compared to 2D ra-
diographic modalities?
MATERIALS AND METHODS
With the objective of decreasing potential biases within
the review process and to report a standardized, quality-
assured, and updated study, the text of the review
was structured in accordance with guidelines from
PRISMA,24 the Cochrane Handbook of Systematic Re-
views of Interventions,25 and Check Review checklist.26
Inclusion Criteria
Both observational (e.g., case series, case-control, and
prospective cohort studies) and interventional trials
(e.g., non-randomized and randomized controlled tri-
als) reporting on the use of CBCT imaging assessing
the impact of fixed orthodontic/dentofacial orthopedic
therapies affecting the periodontal tissues (e.g., alve-
olar bone) were considered eligible for inclusion.
Exclusion Criteria
Case reports, reviews, and studies not including data
on CBCT were excluded from this review.
Outcome Measures
Outcome measures were changes in the alveolar
bone thickness and height around natural teeth and
treatment costs.
962
Volume 88 • Number 10
Search Strategy
Comprehensive search strategies were established to
identify studies for this systematic review. The
MEDLINE (via PubMed) and EMBASE databases
were searched for articles published in the English
language up to and including July 2016, based on the
search strategy developed for MEDLINE: 1) cone-
beam computed tomography OR Spiral cone-beam
computed tomography OR computerized tomogra-
phy, cone-beam OR cone beam computerized to-
mography OR computed tomography, cone-beam
OR CT scan, cone-beam OR tomography, cone-
beam computed OR volumetric computed tomog-
raphy OR volume computed tomography OR CAT
scans, cone-beam; 2) bone volume OR bone thick-
ness OR bone height OR bone loss OR alveolar bone
OR alveolar ridge; 3) cone-beam computed tomog-
raphy OR spiral cone-beam computed tomography
OR computerized tomography, cone-beam OR cone
beam computerized tomography OR computed to-
mography, cone-beam OR CT scan, cone-beam OR
tomography, cone-beam computed OR volumetric
computed tomography OR volume computed to-
mography OR CAT scans, cone-beam; OR bone
volume OR bone thickness OR bone height OR bone
loss OR alveolar bone OR alveolar ridge; 4) den-
toalveolar OR alveoloskeletal OR skeletal relation-
ships OR corticotomy OR clefts OR skeletal anomalies;
5) periodontics OR periodontology OR facilitated or-
thodontics therapy OR (periodontics AND orthodon-
tics) OR orthodontics OR rapid maxillary expansion
OR tooth retraction; 6) dentoalveolar OR alveo-
loskeletal OR skeletal relationships OR corticotomy
OR clefts OR skeletal anomalies; OR periodontics OR
periodontology OR facilitated orthodontics therapy
OR (periodontics AND orthodontics) OR orthodontics
OR rapid maxillary expansion OR tooth retraction; 7)
cone-beam computed tomography OR spiral cone-
beam computed tomography OR computerized to-
mography, cone-beam OR cone beam computerized
tomography OR computed tomography, cone-beam
OR CT scan, cone-beam OR tomography, cone-beam
computed OR volumetric computed tomography OR
volume computed tomography OR CAT scans, cone-
beam; OR bone volume OR bone thickness OR bone
height OR bone loss OR alveolar bone OR alveolar
ridge; AND dentoalveolar OR alveoloskeletal OR
skeletal relationships OR corticotomy OR clefts OR
skeletal anomalies; OR periodontics OR periodontology
OR facilitated orthodontics therapy OR (periodontics
AND orthodontics) OR orthodontics OR rapid maxillary
expansion OR tooth retraction.
Reference lists of potential articles were screened
to search for potentially relevant unpublished studies
or papers not identified by electronic searching.
J Periodontol • October 2017 Mandelaris, Neiva, Chambrone

Assessment of Validity and Data Extraction summaries of the included studies, critical remarks of
One independent reviewer (LC) screened the titles, the literature and evidence quality rating/strength of
abstracts, and full texts of the articles that were recommendation of CBCT procedures were pre-
identified. Data on the following issues were extracted sented. These allowed the assessment of the level of
and recorded: 1) citation, publication status, and year certainty in the evidence (i.e., high, moderate, or low)
of publication; 2) study design; 3) characteristics of for the different treatment modalities displayed in this
participants and group(s); 4) methodologic charac- review, based on the criteria defined by the American
teristics of the trial; and 5) outcome measures. Dental Association Clinical Practice Guidelines
Handbook33 adapted for the purpose of this review
Assessment of Methodologic Quality and Risk of
(see supplementary Tables 1 through 3 in online
Bias of Included Studies
Journal of Periodontology), as reported by Chambrone
For the interventional studies, the methodologic
et al.34 Briefly, this was determined by the following
quality of the trials (see supplementary Appendix 1 in
domains: 1) risk of bias (limitations of the evidence);
online Journal of Periodontology) was evaluated per
2) applicability of evidence; 3) inconsistency or un-
the Cochrane Collaboration’s tool for assessing risk
explained heterogeneity of results; 4) imprecision
of bias,25 as adapted by Chambrone et al.27-31 to
(wide confidence intervals); and 5) high probability of
permit qualification of non-randomized trials. Con-
publication bias.33,34 Consequently, supported on indi-
cisely, the randomization and allocation methods,
vidual studies’ characteristics/outcomes and pooled
blinding of patients and examiners, completeness of
estimates, Clinical Recommendation Summaries sum-
follow-up, selective reporting, and other sources of
marizing ‘‘the strengths and weaknesses of the evidence
bias were classified as adequate (+), inadequate (–),
in terms of benefits and harms’’33,34 were generated.
unclear (?), or not applicable (NA). Based on this
These aimed to depict accurate and explicit rationale for
tool, the risk of bias was classified as follows: 1) low
clinical practice as well as the reasons for the recom-
(all criteria were met); 2) unclear (one or more cri-
mendations. As a result, once the balance between
teria were partially met); 3) high (one or more of the
benefits and harms was decided, the following recom-
criteria were not met).
mendations were applied:33,34 1) strong = evidence
For observational studies, an adapted version28-31
strongly supports providing the intervention; 2) in favor =
of the Newcastle-Ottawa scale32 was used to eval-
evidence favors providing the intervention; 3) weak =
uate the methodologic quality (see supplementary
evidence suggests implementing the intervention after
Appendix 2 in online Journal of Periodontology). The
alternatives have been considered; 4) expert opinion for/
following study aspects were evaluated: 1) selection
supports = evidence is lacking (level of certainty is low),
of study groups, ascertainment of periodontal/bone
and expert opinion guides the recommendation; 5)
conditions, selection of patients with similar health
expert opinion questions the use = evidence is lacking
status, training/calibration of assessors of outcomes,
(level of certainty is low), and expert opinion questions
prospective data collection, and use of clear inclusion/
the use; 6) expert opinion against = evidence is lacking
exclusion criteria; 2) comparability (comparability of
(level of certainty is low), and expert opinion suggests
patients based on study design/analysis and man-
not implementing the intervention; and 7) against =
agement of confounders); 3) outcome (assessment
evidence suggests not implementing the intervention
of bone conditions, criteria applied to evaluate the
or discontinuing ineffective procedures.
bone conditions at last follow-up, and adequacy of
patient follow-up); 4) statistical analysis (appropri- RESULTS
ateness/validity of statistical analysis and unit of
Description of Studies
analysis reported). Points (stars) were given for each
Results of the search and included studies. The
methodologic quality criterion, and each included
search strategy identified 803 potentially eligible
study could receive a maximum of 14 points. Studies
papers, of which 786 articles were excluded after the
with 11 to 14 points (‡78% of the domains satisfac-
titles and/or abstracts were reviewed. A total of 17
torily fulfilled) were arbitrarily considered to be high
potentially eligible papers35-51 were screened, but
quality. Studies with eight to 10 points (57% to 71% of
four48-51 did not meet inclusion criteria. Reasons for
domains fulfilled) were medium quality. Studies with
exclusion are described in supplementary Figure 1 in
fewer than eight points (£50% of domains fulfilled)
online Journal of Periodontology. Thirteen studies were
were low quality.
included in this systematic review (Tables 1 through
Statistical Analyses 4).35-47 Two were interventional,35,37 and 11 were ob-
Data were organized into evidence tables and clus- servational studies.36,38-47 In total, 422 patients were
tered according to the treatment modality to establish evaluated, and all studies were published in full. The
the amount of information and study variations in consensus focused on dentoalveolar bone characteris-
terms of characteristics and results. Additionally, tics rather than considering skeletal and alveoloskeletal

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Table 1.
Characteristics of Included Studies: Rapid Maxillary Expansion

Study Design Procedures Treatment Groups Outcomes

Garib et al.35 Parallel randomized clinical trial, eight Rapid maxillary expansion Haas-type expander Both expanders led to bilateral
patients (11.4 to 13.9 years) with CBCT images taken before expansion Hyrax tooth-borne expander reductions of the buccal bone
posterior crossbites and after 3-month retention period thickness and crestal levels of the
3-month follow-up banded teeth (first premolar and
first molar), whereas the lingual
CBCT and Interdisciplinary Dentofacial Therapy

alveolar bone thickness of these

teeth increased after expansion.
The first premolars had the largest
bone dehiscences, especially in
patients with thinner buccal bone
plate and treated with tooth-borne
expander.
Gauthier et al.36 Case series, 14 patients (16.4 to 39.7 Surgically assisted rapid maxillary Hyrax-type expander Surgically assisted rapid maxillary
years) with posterior crossbites expansion expansion led to a significant
6-month follow-up CBCT images taken before expansion decrease in the buccal bone
and after 6-month retention period thickness on most teeth (especially
on the distal aspect of the first
molars), whereas the lingual alveolar
bone thickness of these teeth
increased after expansion. There
was a significant decrease in the
buccal marginal bone level (i.e.,
height) on the mesial aspect of the
first molars and on the canines.
Rungcharassaeng Parallel controlled clinical trial, 30 Rapid maxillary expansion Four-banded (first premolars and first Both expanders led to bilateral
et al.37 patients (10.3 to 16.8 years) with CBCT images taken before expansion molars) Hyrax-type expander reduction of buccal bone thickness
posterior crossbites and after 3-month retention period Two-banded (first molars) Hyrax-type and buccal marginal bone level (i.e.,
3-month follow-up expander height) of first and second
premolars and first molar. Second
premolars experienced less bone
loss than first premolars and molars.
Volume 88 • Number 10
 J Periodontol • October 2017

Table 2.
Characteristics of Included Studies: Augmented Corticotomy Combined With Accelerated Orthodontic Forces

Study Design Procedures Treatment Groups Outcomes

Coscia et al.38 Case series, 14 patients (mean age: 26.1 Alveolar bone decortication and bone
years) with skeletal Class III relationship augmentation with grafting material
Mean 8.2-month follow-up (corticotomy) followed by the
application of immediate orthodontic
forces
CBCT images were taken before
corticotomy and after the completion
of presurgical orthodontic treatment
Augmented corticotomy plus
accelerated orthodontic movement
Augmented corticotomy combined with
accelerated orthodontic forces led to
an increase in buccal bone thickness
(i.e., prevented the development of
bony dehiscences). Also, this
treatment approach did not lead to
crestal bone loss.

Wang et al.39 Case series, eight adult patients (age not Alveolar bone decortication and bone
reported) with skeletal Class III augmentation with grafting material
relationship (corticotomy) followed by the
Follow-up period not reported application of immediate orthodontic
forces
CBCT images were taken before
corticotomy, after the completion of
presurgical orthodontic treatment,
and at removal of the orthodontic
appliances
Augmented corticotomy plus
accelerated orthodontic movement
Augmented corticotomy combined with
accelerated orthodontic forces led to
an increase in buccal bone thickness
(i.e., prevented the development of
bony dehiscences). Also, this
treatment approach did not lead to
crestal bone loss.
Mandelaris, Neiva, Chambrone

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Table 3.
Characteristics of Included Studies: Anterior Teeth Retraction With Fixed Orthodontic Therapy

Study Design Procedures Treatment Groups Outcomes

Ahn et al.40 Case series, 37 patients (mean age:
26.6 years) with Class I malocclusion CBCT images were taken before
Mean 1.81-year follow-up
Cao et al.41 Cohort, 14 non-smoking patients (22
to 41 years) with chronic
Fixed orthodontic therapy
treatment and after space closure
(anterior teeth retraction)
Fixed orthodontic therapy
CBCT images were taken before and
Extraction of first premolar in each
quadrant + anterior teeth retraction
with fixed orthodontic therapy
Circumferential supracrestal fibrotomy Circumferential supracrestal fibrotomy
+ maxillary incisor retraction/
En masse retraction of anterior teeth
(as part of fixed orthodontic
therapy) led to a significant reduction
of palatal alveolar bone thickness and
height. Also, there was more root
exposure (dehiscence) in the palatal
cervical area than on the buccal side.
+ maxillary incisor retraction/
CBCT and Interdisciplinary Dentofacial Therapy

periodontitis after the completion of maxillary intrusion with fixed orthodontic intrusion led to significant gains in
Mean 19-month follow-up incisor retraction/intrusion therapy clinical attachment level (0.3 mm-
reduction), marginal bone height
(0.65 mm), and buccal bone
thickness (0.54 mm). Also, there was
significant decrease in palatal bone
thickness (0.46 mm).
Lombardo et al.42 Case-control, 22 patients (mean age: Fixed orthodontic therapy Case group: Extraction of first maxillary The extractive and non-extractive
10.5 years) with Class II malocclusion CBCT images were taken before and and second mandibular premolars + therapies led to similar reductions in
Mean 17.5-month (control group) and after the completion of orthodontic anterior teeth retraction + fixed the buccolingual thickness of the
23.1-month (case group) follow-up treatment orthodontic therapy alveolar bone plate. Moreover,
Control group: Fixed orthodontic extractive therapy led to an increase
therapy (no tooth extraction) in the distance from the CEJ to the
base of the defect (interproximal
sites), and the appearance of
infraosseous defects were seen, in
particular in the mandible.
Lund et al.43 Cohort, 171 patients (mean age: 17.4 Fixed orthodontic therapy Extraction of one premolar in each The applied therapy led to a large
years) with Class I malocclusion CBCT images were taken before and quadrant + anterior teeth retraction marginal buccal bone height loss for
152 patients finished the study after the completion of orthodontic with fixed orthodontic therapy anterior teeth.
Mean 20.7-month follow-up treatment
Nayak Krishna Case series, 10 patients (mean age: 15 Fixed orthodontic therapy Extraction of first premolar in each No significant changes in maxillary
et al.44 years) with bimaxillary dentoalveolar CBCT images were taken before and 3 quadrant + anterior teeth retraction buccal bone thickness were
protrusion months after space closure (anterior with fixed orthodontic therapy reported. Conversely, there was
Mean 8-month follow-up teeth retraction) significant loss of buccal bone
thickness for anterior mandibular
incisors.
Volume 88 • Number 10
J Periodontol • October 2017 Mandelaris, Neiva, Chambrone

components as these relationships by themselves do not

a significant decrease of the buccal

directly impact the periodontium. The influence of fixed

cervical third of maxillary incisors

compared to the non-extractive
appliances on the dentoalveolar bone was evaluated.

alveolar bone thickness at the

Case group: Extraction of two maxillary The extractive therapy led to Orthodontic tooth movement produced by removable
appliances and/or aligners was not considered because
Outcomes

such studies were not available.

Use of CBCT to assess periodontal changes
promoted by orthodontic/orthopedic therapy.
Within the included studies, CBCT was proposed to
investigate potential positive or deleterious changes
group

on the alveolar bone surrounding teeth submitted

Characteristics of Included Studies: Anterior Teeth Retraction With Fixed Orthodontic Therapy

to orthodontic or orthopedic forces through fixed ap-

pliances (e.g., braces or fixed maxillary expanders).
premolars (one left and one right) +

The following therapies were available for analysis: 1)

rapid maxillary expansion (three studies35-37); 2)
Control group: Fixed orthodontic
therapy (no tooth extraction)

orthodontic therapy facilitated by corticotomy surgery

Treatment Groups

fixed orthodontic therapy

(two studies38,39); 3) retraction of proclined anterior

teeth with fixed orthodontic therapy (six studies40-45);
and 4) fixed orthodontic therapy for patients who did
not require tooth extraction (two studies46,47).
Risk of bias in the included trials. The quality of
assessment of the included studies was evaluated
using the data extracted from each trial. Both inter-
ventional trials included in the review (randomized
clinical trial and controlled clinical trial) were con-
18 months after the beginning of the
CBCT images were taken before and

sidered to be high risk of bias35,37 (see supplemen-

tary Figure 2 in online Journal of Periodontology).
Regarding the included observational studies, one
was considered to be high quality,43 two of medium
Fixed orthodontic therapy

orthodontic treatment
Procedures

quality,42,45 and the remaining studies of low meth-

odologic quality36,38-41,44,46,47 (Fig. 1).
Individual Study Outcomes and Clinical
Recommendations
The individual study outcomes assisted in generating
a clinical recommendation summary on the use of
CBCT for the evaluation of periodontal changes
promoted by orthodontic/orthopedic therapy. Un-
fortunately, given the high heterogeneity found
Cohort, 12 non-smoking patients

within included studies in terms of design/methods

(mean age: 17 years) with

and primary objectives, meta-analyses could not be

Class I or II malocclusion

calculated to balance that recommendation.

Design

Main findings. The three studies35-37 evaluating

18-month follow-up

the effect of rapid maxillary expansion (conventional

or surgically assisted modalities) unanimously
showed significant bilateral decreases of the buccal
alveolar bone thickness and height (Table 1). These
CEJ = cemento-enamel junction.

findings were more evident around banded (retainer)

Table 3. (continued )

teeth (i.e., first premolar and first molar)35,37 and with

patients who underwent surgically assisted rapid
palatal expansion.36 Moreover, the first premolars
Picancxo et al.45

had the largest bone dehiscences post-treatment,

especially in patients who presented with a thinner
buccal bone plate pretreatment and underwent
Study

therapy using a tooth-borne expander.35 Conversely,

these studies also reported an increase in the lingual

967
CBCT and Interdisciplinary Dentofacial Therapy Volume 88 • Number 10

alveolar bone thickness of these teeth supporting

dehiscence (loss of vertical bone) and

Non-extraction orthodontic therapy + There were significant increases in buccal
greater dehiscence development. The

during presurgical orthodontics. After

cortical bone at the apex level are at

decrease of buccal bone thickness at

the fixed maxillary expanders.35-37 None of these

development of such vertical bone

orthognathic surgery, no additional

the midroot of mandibular incisors
Patients presenting thin pretreatment

loss may promote a ‘‘thinning’’ of

studies compared the outcomes of 3D CBCT to 2D

an increased risk of experiencing

conventional radiographic analysis.
With respect to the assessment of the periodontal
Outcomes

effects of bone augmentation and corticotomy

buccal cortical bone.

changes were found.

surgery (Table 2), two studies38,39 found that this
therapeutic approach: 1) promoted an increase of
buccal alveolar bone thickness (i.e., prevented the
development of bony dehiscences) and 2) did not
promote significant changes on crestal bone loss
levels (i.e., deleterious bone height changes).
Within the five studies40,42-45 included in this
systematic review that evaluated periodontal alter-
mandibular setback sagittal split ramus
osteotomy with rigid internal fixation
Characteristics of Included Studies: Fixed Orthodontic Therapy (non-extraction patients)

ations following extraction of first or second pre-

Non-extraction orthodontic therapy

molars and en masse retraction of anterior teeth by

fixed orthodontic appliances (Table 3), it was dem-
Treatment Groups

onstrated that significant changes in the alveolar

ridge thickness and height may occur. These
changes were evident for both the palatal/lingual
bone40,42 and buccal43,45 bone plates of anterior
teeth. One study42 compared the potential differ-
ences in alveolar bone height and thickness between
patients submitted to extraction and non-extraction
therapies. Both treatment approaches led to similar
reductions in the buccolingual thickness of the al-
veolar bone plate, but the authors reported the de-
years) with Class I or II malocclusions CBCT images were taken before and

CBCT images were taken before and

velopment of infraosseous defects at the extraction

sites, in particular in the mandible.42 In addition, one
study41 evaluated the effect of circumferential su-
Garlock et al.46 Case series, 57 patients (mean age: 18.7 Fixed orthodontic therapy

Case series, 25 patients (mean age: 26.3 Fixed orthodontic therapy

pracrestal fiberotomy + maxillary incisor retraction/

Procedures

intrusion within periodontally compromised patients

presenting pathologic tooth migration. For those
after treatment

after treatment

patients, the proposed treatment approach promoted

a significant gain in the buccal bone thickness at the
apical level, but at the same time it led to a pro-
portional reduction of the palatal bone thickness.41
The two studies46,47 evaluating the effect of fixed
orthodontics within patients not requiring tooth
extraction showed an increase in bone dehiscences
(i.e., vertical bone loss covering the buccal aspect of
teeth), as well as a thinning of buccal cortical bone
years) with skeletal Class III
Mean 22.7-month follow-up

(Table 4). These outcomes seemed more pro-

mandibular prognathism
Mean 28-month follow-up
Design

nounced for patients with thin pretreatment cortical

bone. In addition, none of the included studies35-47
compared the accuracy of images acquired by 3D
versus 2D (this issue seemed directly associated
with the fact that 2D radiographs are not capable of
measuring buccal plate changes and that those
could be used only to evaluate crestal bone
changes).9,11
Lee et al.47

Clinical Recommendation Summary

Table 4.

Use of CBCT for the assessment of alveolar bone

Study

changes promoted by orthodontic/dentofacial

orthopedic therapies is recommended with a high

968
J Periodontol • October 2017
Figure 1.
Methodologic quality of included observational studies. Points assigned to respective study.
level of certainty. In general terms, CBCT led to the
acquisition of precise images of the vertical and hor-
izontal alterations promoted by orthodontic/orthope-
dic forces. Interpretation and understanding of
pretreatment regional anatomy using 3D data was
important to objectively identify which patients were at
risk for developing detrimental periodontal conditions,
such as alveolar bone loss and gingival recession. No
pooled estimates on alveolar bone thickness or height
or bone plate width could be calculated.
No adverse events or harms were reported, but the
effect of radiation doses could not be calculated. The
benefit-harm assessment (net benefit rating) found
that the benefits obtained by CBCT for the assess-
ment of alveolar bone changes prior to and following
orthodontic therapy outweigh potential for harm
(radiation exposure and cellular changes promoting
neoplasia, especially in skeletally immature patients).
The strength of clinical recommendation33,34 is
strong (evidence strongly supports implementing
CBCT for the assessment of alveolar bone alterations
prior to and following orthodontic/dentofacial or-
thopedics therapies), especially for skeletally mature
patients.
DISCUSSION
Perhaps the most difficult challenge facing the pro-
fession today is that involving treatment planning.
Without accurate and comprehensive diagnostic in-
formation, any level of treatment planning may be
impaired. This becomes even more complex when
attempting to restore sustainable oral health conditions
and the interaction of multiple disciplines/specialties
are required (e.g., IDT). According to Proffit et al.
a total of 75% of the United States population has some
Mandelaris, Neiva, Chambrone
form of malocclusion. With an
aging patient population whose
life expectancy is increasing, as
is the desire for improved oral
health, the need for orthodontic
services to overcome decades of
tooth wear and subsequent mi-
gration is often required.
Three-dimensional imaging
modalities involving CBCT have
exponentially improved the abil-
ity to evaluate regional anatomy.
Such advancements, however,
have not expanded into the
diagnostic inquiry centered on
the preservation of the natural
dentition. Rather, CBCT imaging
has remained limited (for the
most part) to dental implant and
related adjunctive therapies.
The purpose of this systematic
review was to evaluate whether CBCT imaging
should be used to assess dentoalveolar relation-
ships critical to determining risk assessment and
help determine as well as improve periodontal treat-
ment needs in patients requiring orthodontic tooth
movement.
It is recognized that alveolar bone is a dynamic and
unique organ system that is tooth dependent. It orig-
inates from the dental follicle during embryogenesis. In
comparison, basal/skeletal bone is more static and
structural in function. It develops de novo from neural
crestal cell migration and condensing mesenchyme
interactions in conjunction with developing neuro-
muscular structures.53,54 A key question critical to IDT
and tooth movement remains to be answered. That
question is: What is the modulus of elasticity of alveolar
bone and to what extent is alveolar bone flexible in vivo
and in humans? In other words, how far and under what
conditions can teeth be moved without developing
iatrogenic sequelae on the dentoalveolar bone com-
partment and/or periodontium? According to most
reports to date, studies have measured only the base of
the alveolar process55,56 and not the alveolar bone
socket itself.57 Further, because remodeling of alveolar
bone is known to be rapid and is often young in its life
cycle, its mineralization and stiffness may be low. This
has raised questions on cause and effect. The question
arises: Is alveolar bone flexible because it needs to be
adaptive and to assist periodontal soft tissues in their
deformation or is the flexibility a byproduct of the rapid
turnover that weakens the system? To date, there
exists too little information on in vivo mechanics to
validate an answer.57 With the emerging influence and
52 growing popularity of CBCT imaging in the profession,
our goal was to pose a question that is fundamental
969
970
Table 5.
Patterns of Dentofacial Disharmony/Skeletal Malocclusion and Benefit From Periodontal-Orthodontic Therapy
Involving Corticotomy and Dentoalveolar Bone Augmentation (i.e., SFOT/PAOO)
Malocclusion Anatomic Description
Transverse maxillary deficiency
Skeletal Class II, division 2 dentofacial
disharmony malocclusion with severely
upright or retroclined maxillary incisors
Skeletal Class II or III dentofacial disharmony
malocclusion with maxillary incisor
proclination requiring labial root torque
Defining Characteristics
Highly prevalent malocclusion case type
Usually presents with excess curve of
Wilson
Typical correction involves SARPE, which
decreases buccal alveolar bone
Notoriously difficult cases to decom-
pensate due to thick crestal bone
May require 20 degrees of torque, ex-
ceeding orthodontic capabilities
Crown is in a relatively good position
Root position is unfavorable and requires
movement
Dentoalveolar bone volume is limited to
accomplish ideal decompensation
Treatment Planning Challenges and
Opportunities
SFOT/ PAOO allows more optimal de-
compensation and correction of excess
curve of Wilson as well as idealizes axial
inclination of teeth by augmenting
buccal alveolar bone.
Skeletal movement needed with OGS
may become purely expansion with
improved decompensation (if possible).
The use of SFOT/ PAOO induces RAP,
which can help achieve more ideal
decompensation for the orthodontist
because the teeth move in a deminer-
alized bone matrix, which facilitates
movement, may improve the predict-
ability of tooth movement, and de-
creases treatment time.
Proclination correction requires labial root
torque while holding incisor crown
position.
Risk is pushing roots out of the alveolar
bone and exceeding the alveolar
boundary conditions (i.e., orthodontic
walls).
Conventional correction may include ex-
traction and/or skeletal anchorage for
maximum space closure.
Conventional correction necessitates in-
creasing a negative overjet and a larger
skeletal correction.
If OGS is needed, one-jaw surgery may
now become a double-jaw procedure.
Treatment Options Using SFOT Prior
to OGS
SFOT/ PAOO to expand and increase
buccal alveolar boundary conditions
(i.e., orthodontic walls) laterally, allow-
ing decompensation to occur through
buccal root torque.
LeFort I osteotomy OGS may reduce the
need for tipping to optimize posterior
CBCT and Interdisciplinary Dentofacial Therapy
articulation.
SFOT/ PAOO to induce RAP and allow
decompensation to occur in a demin-
eralized bone matrix while augmenting
the dentoalveolar bone complex.
OGS thereafter to align skeletal discrep-
ancies once decompensation is cor-
rected and inter-/intra-arch dimensions
are aligned for such correction.
SFOT/ PAOO to develop dentoalveolar
bone and augment/enhance alveolar
boundary conditions (i.e., orthodontic
walls), facilitating tooth movement and
expanding tooth movement capabilities.
Volume 88 • Number 10
 Table 5. (continued )
Patterns of Dentofacial Disharmony/Skeletal Malocclusion and Benefit From Periodontal-Orthodontic Therapy
Involving Corticotomy and Dentoalveolar Bone Augmentation (i.e., SFOT/PAOO)
Malocclusion Anatomic Description Defining Characteristics
Skeletal Class III dentofacial disharmony Very limited alveolar bone to move teeth
malocclusion cases with protrusive and safely
retroclined mandibular incisors ‘‘Teeth on a pedestal’’ presentation on
CBCT cross section/sagittal view
Skeletal Class II dentofacial disharmony Severely proclined mandibular incisors
malocclusions with mandibular incisor requiring decompensation for future
proclination needing labial root torque OGS
Limited dentoalveolar bone to accomplish
labial root torque movement while al-
lowing roots of teeth to be placed in
bone
OGS = orthognathic surgery; RAP = regional acceleratory phenomenon.
971
Treatment Planning Challenges and
Opportunities
Decompensation of mandibular incisor
position is impossible with labial crown
torque as it can create dehiscences and
periodontal problems.
Conventional OGS therapy includes an-
teroposterior reduction genioplasty,
which may not look favorable and does
not correct the dentoalveolar bone
deficiency/volume etiologic problem.
Typical plan: extract and decompensate
for OGS.
Not an ideal plan when patient has an
ideal Holdaway ratio or no additional
overjet is needed for desired skeletal
correction.
If the patient has obstructive sleep apnea,
this condition might become worse
before becoming better.
Treatment Options Using SFOT Prior
to OGS
SFOT/PAOO to provide dentoalveolar
J Periodontol • October 2017
bone and alveoloskeletal bone aug-
mentation and to allow proclination of
mandibular incisors to occur
SFOT/PAOO to enhance orthodontic
decompensation and apply labial root
torque and place roots in bone for
decompensation
OGS thereafter to correct skeletal dis-
crepancy
Mandelaris, Neiva, Chambrone
CBCT and Interdisciplinary Dentofacial Therapy
Figure 2.
A and B) Coronal views of maxillary transverse deficiency, highlighting maxillary first molars as well as required decompensation movements needed
for planned orthognathic surgery to correct skeletal disharmony. Note that severe adverse changes are likely to occur to buccal alveolar bone with
decompensation movements needed.
to periodontal-orthodontic interactions and focus on
anatomic changes that could only be evaluated by
CBCT data: Does CBCT imaging improve diagnostic
acumen and influence periodontal decision making in
patients requiring orthodontic tooth movement com-
pared with 2D radiographic modalities? Apart from
the use of CBCT or 2D radiographs for orthodontic
treatment planning, it must be clear that both imaging
modalities may lead to cytotoxic effects in oral mucosa
cells (CBCT being more aggressive because of
the superior levels of radiation dose used). CBCT and
2D radiographs should be used when essential to
treatment planning and follow the ‘‘as low as reason-
ably achievable’’ (ALARA) principle.58
This BEC on CBCT of 13 studies exhibited a re-
liable summary of the alveolar bone alterations
promoted by four different orthodontic/dentofacial
orthopedic treatment approaches. The studies can
be categorized as: 1) orthodontic expansion using
either conventional orthodontic therapy combined
with orthognathic surgery (surgically assisted rapid
palatal expansion [SARPE]), conventional orthodontic
therapy alone, or corticotomy-assisted orthodontic
therapy combined with bone augmentation; and
2) orthodontic retraction of proclined maxillary inci-
sors. Overall, CBCT provided accurate measure-
ments of alveolar bone thickness, as well as the
development of buccal bone dehiscences that may
alter decision-making to avoid iatrogenic sequelae
from orthodontic tooth movement.
972
Volume 88 • Number 10
With the exception of corticotomy surgery in-
volving bone augmentation to facilitate orthodontic
therapy (commonly recognized as surgically facili-
tated orthodontic therapy [SFOT]20 or periodontally
accelerated osteogenic orthodontics [PAOO]),59 the
other three therapies evaluated in this review showed
strong evidence of vertical bone loss that may trigger
the development or progression of gingival recession
during or after orthodontic treatment. Further, while
studies were only available to review fixed appli-
ances, it can be argued that alveolar bone changes
produced through aligner therapy or removable ap-
pliances would be similar to that produced by fixed
appliances.
A thin periodontal phenotype/buccal alveolar wall
may be a critical factor associated with the de-
terioration of the periodontal attachment, especially
for non-surgical/surgical maxillary expansion where
orthodontic treatment is indicated to decompensate
mandibular incisors.38,60,61 Such regional anatomy
vulnerability may call upon alternative orthodontic
approaches, such as corticotomy surgery with alveolar
augmentation, to offset the potential for iatrogenic
sequelae. This seems valid for the sagittal correction/
decompensation of skeletal Class III patients who ex-
hibit protrusive and severely retroclined mandibular
incisors where the orthodontic envelope is restricted
and the corresponding periodontal phenotype is thin. In
addition, alternative approaches involving corticotomy
surgery with alveolar augmentation may be beneficial
J Periodontol • October 2017 Mandelaris, Neiva, Chambrone

Figure 3.
A) Preoperative frontal view of patient with transverse maxillary deficiency, maxillary hypoplasia, and Class III dental and skeletal malocclusion. Note
bilateral crossbite, dental compensations, and advanced recession-based AL. B and C) Maxillary right and left side intrasurgical photos demonstrating
significant dentoalveolar deficiencies. Orthodontic tooth movement cannot be safely undertaken without dentoalveolar bone augmentation and
periodontal regeneration efforts. Corticotomies and selective dentoalveolar decortication performed to stimulate the regional acceleratory phenomena
and a demineralized bone matrix to encourage angiogenesis for bone grafting. D) Periodontal regeneration and dentoalveolar bone augmentation
performed using cancellous allograft directly against the dehisced and fenestrated root surfaces, followed by corticocancellous mineralized freeze-dried
bone allograft. E) Orthodontic decompensation and tooth movement completed with significant improvement in periodontal and dentoalveolar bone
phenotype achieved secondary to gains in alveolar boundary conditions through periodontal regeneration and dentoalveolar bone augmentation efforts.
Unilateral crossbite remains on the right side. Patient can now proceed with unilateral orthognathic surgery to manage his skeletal malocclusion and
remaining dentofacial disharmony, which was not correctable by dentoalveolar bone surgery alone. The orthognathic surgery treatment needs via
unilateral SARPE have been simplified (unilateral versus bilateral) for the patient. In addition, the patient’s periodontal phenotype has been improved
through dentoalveolar bone augmentation and mucogingival augmentation (evidenced by gain in root coverage, improvement in tissue thickness, and
increased zone of keratinized and attached gingiva through simultaneous interpositional connective tissue grafting). Lastly, the decompensation
orthodontic tooth movement outcome has been exceeded when compared to what could have been achieved via conventional therapy as a result of
gains in alveolar boundary conditions. Orthodontics by Howard Spector, DDS (Chicago, IL).

in patients submitted to extraction or non-extraction movement.16,38,39 It is also a promising treatment al-

conventional orthodontics with fixed appliances de-
pending upon their presenting regional anatomy
characteristics and the planned orthodontic tooth
movement demands.40-47 Risk assessment conducted
by CBCT gave support to the findings of the recent
systematic review on periodontal soft tissue non-root
coverage procedures:18 1) sites with ‘‘<2 mm of at-
tached gingiva should undergo gingival augmentation
before the initiation of orthodontic therapy’’;18 2) the
assessment of extension of labial tooth movement is
critical to the magnitude of force in soft and hard tissue
level alteration during orthodontic treatment.18 Un-
fortunately, these soft tissue approaches do not entirely
address the etiology of the recession-based AL vul-
nerability, which is a deficiency in dentoalveolar bone
volume. Depending on the circumstance, emerging
surgical approaches involving corticotomy and den-
toalveolar bone augmentation (i.e., SFOT, PAOO)
may better manage the core problem of human peri-
odontal anatomy in vulnerable patients requiring tooth
ternative that expands orthodontic capabilities while
promoting a robust periodontium.
The volumetric nature of digital imaging com-
munication in medicine (DICOM) data acquired by
CBCT of the dentofacial and maxillofacial skeletal
complexes allows for collaborative planning and
an accountability-based outcome assessment. The
acquired DICOM data can be shared with multiple
disciplines and integrated into therapy-specific mo-
dalities required for patient treatment. For example,
decompensation tooth movement and orthognathic
surgery necessary for dental and skeletal correction
of malocclusions can now be measured against the
risk of worsening dentoalveolar structures of the
periodontium. While robotically designed and shaped
archwires for orthodontics and virtually planned cut-
ting guides for skeletal surgery can be fabricated using
DICOM-dependent software systems, the impact of
such treatment on the periodontium cannot be ade-
quately assessed using traditional radiography. 3D

973
CBCT and Interdisciplinary Dentofacial Therapy
Figure 4.
3D CBCT reconstruction of a patient with transverse maxillary deficiency demonstrating A) initial exam presentation where crowding and dentoalveolar
deficiencies abound, B) simulated final orthodontic tooth position but within native bone architecture (note advanced bone loss secondary to
orthodontic tooth movement occurring within deficient alveolar boundary conditions), and C) final orthodontic outcome following orthodontic therapy
supported by periodontal regeneration and bone augmentation to manage dentoalveolar deficiencies.
CBCT imaging technology allows for virtual assessment
of outcomes through specialty-specific proprietary
software. This enables the periodontist-orthodontist
team to proactively assess risk and benefit, thereby
providing a basis for measureable risk and informed
consent as well as developing suitable treatment
plans that are more dynamic in context, less re-
actionary to intraoperative complications, and more
proactively patient-centric.
Five dentofacial disharmony malocclusions are
described in Table 5. The risk of exceeding alveolar
boundary conditions in the management of these
malocclusions can be identified using CBCT imaging.62
Such imaging and 3D planning can help determine
when supportive dentoalveolar bone surgical therapies
should be considered to optimize decompensation and
planned translational orthodontic tooth movements.
The five dentofacial disharmony malocclusions that
especially benefit from CBCT imaging include: 1)
transverse maxillary deficiency with compensating
excess curve of Wilson (commonly recognized clini-
cally in the patient who demonstrates unilateral or bi-
lateral posterior crossbite) (Figs. 2 through 4); 2) Class
II, division 2 dentofacial disharmony malocclusion with
severely upright or retroclined maxillary incisors; 3)
skeletal Class II or Class III dentofacial disharmony
malocclusion with maxillary incisor proclination re-
quiring labial root torque; 4) skeletal Class III dento-
facial disharmony malocclusion with protrusive and
compensating retroclined mandibular incisors; and 5)
skeletal mandibular dentofacial disharmony deficiency
exhibiting a Class II, division 1 malocclusion with
compensating excessive mandibular incisor proclina-
tion with or without crowding.
The addition of 3D CBCT imaging opens many
possibilities and expanded opportunities for improved
974
Volume 88 • Number 10
patient outcomes in interdisciplinary therapy, and
periodontal-orthodontic therapy in particular.63 As
future advancements occur in radiation exposure al-
gorithms, reducing the risk for deleterious cellular
changes associated with ionizing radiation, screening
and diagnostic modalities involving CBCT 3D imaging
may become more mainstream. Certainly, improved
diagnostic imaging improves the ability to make key
decisions in the development of meaningful treatment
plans for patients involved with IDT that includes or-
thodontic tooth movement.
Quality of the Evidence, Potential Biases, and
Limitations in the Review Process
This systematic review is the first to assess the use of
CBCT to identify potential alterations of the alveolar
bone caused by orthodontic tooth movement. The
topic is critical for both periodontists and orthodon-
tists who often collaborate in managing malocclu-
sions. The use of CBCT imaging to expose the
anatomic reality and help assess periodontal risk for
the safest, most predictable, and most sustainable
outcome for patients requiring orthodontic tooth
movement is promising.
Given the information presented in this BEC, the
following considerations are noteworthy: 1) available
evidence is mostly derived from prospective and retro-
spective case series; 2) no controlled clinical trials
comparing the accuracy of 3D versus 2D imaging in
detecting bone changes during or after orthodontic/
orthopedic therapy could be included and analyzed; and
3) it was not possible to combine studies into meta-
analysis due the substantial degree of heterogeneity
found in terms of the studies’ design and lack of control
groups. Another aspect valid for this review is how the
impact of radiation could restrict the regular use of CBCT
J Periodontol • October 2017
in orthodontics. Unfortunately, none of the included
studies evaluated the potential harm of CBCT nor its
costs. It has been shown, however, that the radiation
dose of CBCT imaging is comparable to traditional
full-mouth plain-film periapical radiographs.64,65 When
compared with panoramic radiographs, the dose is up to
seven times higher, although the accuracy of panoramic
films is significantly compromised compared with
CBCT.66 As previously stated, with any imaging
modality the ALARA principle should be adhered to,
and each patient should be evaluated individually
based on their unique treatment needs and set of
circumstances.
There exist scenarios when 3D CBCT imaging may
not be selected for periodontal-orthodontic therapy.
Minor dental crowding requiring limited or minimal
orthodontic decompensation in the presence of a
robust mucogingival environment and/or when 2D
radiographic data interpretation is sufficient to make
treatment-planning decisions are two examples.
Most of these decisions continue to be subjective, and
their outcomes rely on the knowledge, skill, and
judgment of the treating clinicians. In the end, each
clinician and interdisciplinary team will need to de-
termine which level of diagnostic imaging data are
sufficient to make treatment decisions (and sub-
sequently execute therapy) that is safe and pre-
dictable for the patient who is under their care.
It is clear that many aspects of CBCT imaging
should be taken into consideration prior to and for
executing treatment. At this time, however, the evi-
dence demonstrates that there are significant di-
agnostic advantages of CBCT imaging in providing
pretreatment periodontal risk assessment for patients
requiring orthodontic tooth movement, especially
those who are skeletally mature.
CONCLUSIONS
CBCT imaging can improve diagnostic acumen of
alveolar bone alterations caused by orthodontic tooth
movement and can influence periodontal decision
making. Pretreatment orthodontic CBCT imaging
can assist clinicians in selecting preventive or in-
terceptive periodontal corticotomy and augmenta-
tion surgical requirements, especially for treatment
approaches involving buccal tooth movement at the
anterior mandible or maxillary premolars to prevent
deleterious alveolar bone changes.
Implication for Research and Practice
Despite the lack of controlled clinical trials com-
paring the reliability of 3D to 2D imaging in detecting
alveolar changes promoted by orthodontic tooth
movement, the use of CBCT should be considered for
use to identify those patients at an increased risk of
developing ABL. This assumption seems more suit-
Mandelaris, Neiva, Chambrone
able for skeletally mature patients presenting with
a thin periodontal phenotype prior to treatment in-
volving orthodontic tooth movement.
ACKNOWLEDGMENTS
The American Academy of Periodontology Best Ev-
idence Consensus meeting on cone-beam computed
tomography was sponsored by Carestream Dental
(Atlanta, Georgia). Dr. Mandelaris has received lecture
fees from Carestream Dental, Materialise Dental,
ClaroNav, and Geistlich Pharma. Drs. Neiva and
Chambrone report no conflicts of interest relative
to this Best Evidence Consensus review.
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Correspondence: Dr. Leandro Chambrone, Rua da Mooca,
2518, cj13 03104-002, São Paulo, SP, Brazil. Email:
leandro_chambrone@hotmail.com.
Submitted December 7, 2016; accepted for publication
May 19, 2017.
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