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Radiographic Interpretation

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Radiographic Interpretation

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2 Radiographic

Interpretation
MADHU K. NAIR, MARTIN D. LEVIN, and UMADEVI P. NAIR

CHAPTER OUTLINE Radiographic Interpretation Diagnosis of Endodontic Treatment

Imaging Modalities Failures
Image Characteristics and Processing Intraoperative or Postoperative
Digital Imaging and Communications in Assessment of Endodontic Treatment
Medicine Complications
Diagnostic Tasks in Endodontics Vertical Root Fractures
Diagnosis and Healing Overextended Root Canal Obturation
Material
Three-Dimensional Imaging
Separated Endodontic Instruments
Principles of Cone Beam Computed
Tomography Calcified Canals
Voxels and Voxel Sizes Perforations
Field of View Presurgical Treatment Planning
Diagnostic Task Dentoalveolar Trauma
Type of Patient Internal and External Root Resorption
Spatial Resolution Requirements Endodontic Treatment Outcomes
Assessment
Imaging Tasks Improved or Simplified
by Cone Beam Volumetric Computed Dental Implant Case Planning
Tomography 3D-Guided Endodontics
Differential Diagnosis Image Perception and Viewing
Lesions of Endodontic Origin Environment
Lesions of Nonendodontic Origin Future of Cone Beam Computed
Tomography
Evaluation of Anatomy and Complex
Morphology Magnetic Resonance Imaging
Dental Anomalies Conclusions
Root Canal System Morphology

Radiographic Interpretation [MRI]). Interventional and noninterventional imaging mo-

dalities are also available. Imaging modalities using ionizing
Interpretation of information captured by radiographic im- radiation are most frequently used in endodontic diagnoses.
aging modalities is central to the diagnostic process. It is The different image capture modalities include digital recep-
very important to capture a diagnostically useful image tors using different technologies.
using appropriate exposure parameters and view it with
interactive manipulation of brightness and contrast or win- IMAGING MODALITIES
dow/level (for cone-beam computed tomography [CBCT]
studies) in an optimal environment to adequately evaluate Digital radiography using electronic sensors or photostimu-
anatomy and diagnose pathoses. Accurate interpretation lable phosphor (PSP) plates is widely used in endodontics.
of root and canal morphology, determination of radio- Digital imaging modalities in endodontics use different im-
graphic canal length, diagnosis of radicular and periradic- age capture technologies, which include a charge-coupled
ular disease (Fig. 2.1), and postsurgical and long-term device (CCD), a complementary metal oxide semiconductor
evaluation of the outcome of endodontic treatment are (CMOS), or a PSP (also sometimes referred to as an indirect
some of the routine diagnostic imaging tasks in endodon- acquisition modality).
tics.218 Systematic and methodical interpretation processes CCD-based solid-state sensors were used extensively
must be followed for all images. Recognition of anatomy, in endodontics initially. However, the earlier generation
anatomic variants, and pathologic conditions or deviations sensors had a smaller active area and limited x-ray absorp-
from normal is important. Various imaging modalities exist tion and conversion efficiency, in addition to being bulky.
in radiology. Some use ionizing radiation, whereas others Sensors use an array of radiation-sensitive elements that
use ultrasonic waves (ultrasonography [US]) or powerful generate electric charges proportionate to the amount of
external magnetic fields (magnetic resonance imaging incident radiation. To reduce the amount of radiation
34

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2 • Radiographic Interpretation 35

A B
Fig. 2.1 A, A well-angulated periapical radiograph of the maxillary right first molar taken during a diagnostic appointment for endodontic evaluation
of the maxillary right quadrant. At first glance, there is little radiographic evidence of significant or periradicular change. B, Contemporaneous CBCT
image of same tooth gives an entirely different perspective; periapical changes are visible on all three roots in all three anatomic planes of section.
(B taken with J. Morita Veraviewepocs 3D [J. Morita, Osaka, Japan].)

A B
Fig. 2.2 A and B, High-resolution complementary metal oxide semiconductor (CMOS) sensors are available from many manufacturers. Note that Figure
In B, wireless CMOS sensors transmit images to the chairside workstation by 2.4 GHz radiofrequency. (Courtesy SIRONA DENTAL SYSTEMS, Long
Island City, NY.)

needed to capture an image, a light-sensitive array was USB utilization, and wireless applications are feasible. Wire-
developed that uses a scintillation layer laid on top of the less sensors are available (Fig. 2.2). However, radiofre-
CCD chip or added with a fiberoptic coupling. The generated quency interference may be a problem with these sensors.
charge is read out in a “bucket brigade” fashion and trans- The current Wi-Fi sensor is less bulky and has a wire
ferred to an analog-to-digital converter in the frame grab- attached to it that enables transmission via 802.11 b/g
ber assembly of the workstation. The digital information is standard. It uses a lithium-ion polymer battery that can last
processed, and an image is formed. CMOS-based sensors, on for approximately 100 exposures.
the other hand, have an active transistor at each element Yet another type of sensor uses PSPs for image capture.
location. The area available for signal generation is rela- PSP technology is also referred to as computed radiography
tively less, and there is a fixed pattern noise. These sensors (CR).114,199 Unlike the CCD and CMOS sensors, PSP sensors
are less expensive to manufacture and have been shown to are wireless. The phosphor is activated by a process called
be equally useful for specific diagnostic tasks.114 Unlike the doping, which enables charges to be generated and stored
CCD, the CMOS chip requires very little electrical energy; when exposed to radiation. A latent image is stored in
therefore, no external power supply is needed to support the sensor, and a PSP reader with a laser beam of specific

wavelength is used to read out the image. Previously cap- establishes nine new recommendations for image process-
tured images can be erased by exposing the PSP sensor to ing of conventional film.
white light. PSP plates can be damaged easily by scratching, A strong argument can be made for clinicians to switch
but they are not as expensive as CCD or CMOS sensors. In- to a direct digital radiography (DDR) system to avoid all
complete erasure of the image can lead to ghost images the drastic changes necessary to ensure compliance with
when the plate is reused, and delayed processing can result the new recommendations. Even though restriction of an
in a decrease in image clarity.6 PSP-based sensors are used intraoral dental x-ray beam is mandated by federal law to
in high-volume scenarios. Spatial resolution is lower with a circle no greater than 7 cm, rectangular collimation
this type of sensor, but it has a wider dynamic range. These has been proven to significantly reduce the radiation dose
sensors can tolerate a wider range of exposures to produce to the patient and is strongly recommended in the NCRP
a diagnostically useful image. Report #145.
Radiation dose continues to be a concern with all imag- The American Dental Association (ADA) Council on
ing studies. The lowest possible dose must be delivered for Scientific Affairs has made the following statement:
each study. Most dental offices would not be in compliance
with the latest recommendations of the National Council Tissue area exposed to the primary x-ray beam should not
for Radiation Protection (NCRP) on reducing the radiation exceed the minimum coverage consistent with meeting diagnos-
dose from intraoral radiographs (Box 2.1). Two terms have tic requirements and clinical feasibility. For periapical (PA)
been specifically defined in the NCRP’s report. The terms and bitewing radiography, rectangular collimation should be
shall and shall not indicate that adherence to the recom- used whenever possible because a round field beam used with a
mendation would be in compliance with the standards of rectangular image receptor produces segments of the beam
radiation safety. The terms should and should not indicate circle that are not used in receptor exposure, which causes
prudent practice and acknowledge that exceptions may unnecessary radiation exposure to the patient.4
be made in certain circumstances. In addition, the report

IMAGE CHARACTERISTICS AND PROCESSING

Box 2.1 Recommendations of the National Spatial resolution achieved with current generation digital
Council on Radiation Protection sensors is equally good or better than that of conventional
1. Dentists must examine their patients before ordering or intraoral radiographic film. Intraoral film has a resolution of
prescribing x-ray images (this is not a new guideline). 16-line pairs per millimeter (lp/mm) as measured using a
2. The use of leaded aprons on patients shall not be required resolution tool, and it increases to 20 to 24 lp/mm with mag-
if all other recommendations in this report are rigorously nification. Spatial resolution is defined as the ability to display
followed (read full Report #145). two objects that are close to each other as two separate enti-
3. Thyroid shielding shall be used for children and should ties. Contrast resolution is defined as the ability to differentiate
be provided for adults when it will not interfere with the between areas on the image based on density. Most diagnos-
examination (e.g., panoramic imaging). tic tasks in endodontics require a high-contrast resolution.142
4. Rectangular collimation of the beam, which has been recom-
However, image quality is not only a function of spatial reso-
mended for years, shall be routinely used for periapical radio-
graphs. Each dimension of the beam, measured in the plane
lution. The choice of appropriate exposure parameters, sen-
of the image receptor, should not exceed the dimension of sor properties, the image processing used, and viewing con-
the image receptor by more than 2% of the source-to-image ditions and modalities directly affect diagnostic accuracy.
receptor distance. Similar collimation should be used, when Postprocessing of images may be carried out to alter im-
feasible, for bitewing radiographs. age characteristics. Radiographs need not be reexposed if
5. Image receptors of speeds slower than ANSI speed Group E image quality is not adequate. Diagnostic information can
films shall not be used for intraoral radiography. Faster recep- be teased out of the image if appropriate image processing
tors should be evaluated and adopted if found acceptable. For is used. However, the original image must be acquired with
extraoral radiography, high-speed (400 or greater) rare earth optimal exposure parameters to accomplish meaningful
screen-film systems or digital-imaging systems of equivalent
image processing.212 Suboptimally exposed images cannot
or greater speed shall be used.
6. Dental radiographic films shall be developed according to the
be processed to yield diagnostic information, which may
film manufacturer’s instructions using the time-temperature lead to a reduction in the diagnostic accuracy of the image.
method. In practical application, this means that sight devel- Image enhancement must be task specific. Signal-to-noise
opment (reading wet x-ray films at the time of the procedure) ratio (SNR) must be optimized to extract necessary infor-
shall not be used. mation from the image. The bit-depth of images also has a
7. Radiographic techniques for digital imaging shall be adjusted direct relationship to image quality. It indicates the number
for the minimum patient dose required to produce a signal- of shades of gray that the sensor can capture for display. For
to-noise ratio sufficient to provide image quality to meet example, an 8-bit image can depict 256 shades of gray.
the purpose of the examination. Most sensors are 12 or 14 bits in depth, capturing 4096 or
8. Clinicians designing new offices or remodeling existing
65,536 shades of gray, respectively. If the sensor captures
locations will need shield protection to be provided by a
qualified expert.
several thousand shades of gray, the image can be manipu-
lated through enhancement techniques to display those
Modified from the National Council on Radiation Protection and Measure- shades of gray that best depict the anatomy of interest. The
ments: Radiation protection in dentistry, Report #145, Bethesda, MD, human visual system is limited in the number of shades of
2003. Available at [Link]/Reports/145. gray that can be read at any point in time. Therefore, image

enhancement is a must for all images, so as to delineate partial compliance. However, proprietary DICOM images
signals of interest through manipulation of the grayscale. are still produced in different systems, with the capability to
Most endodontic tasks require a high contrast and thus a export in universal DICOM format as needed. Diagnostic
shorter grayscale. images are best saved as DICOM files to preserve image fidel-
Digital radiographs can be saved in different file formats. ity or as tiff files with no compression. Diagnosis suffers
Several file formats are available: DICOM (Digital Imaging when images undergo lossy compression.64,123,217
and Communications in Medicine); tiff (tagged image file Based on the DICOM model, the ADA Standards Commit-
format); jpeg (joint photographic experts’ group); gif (graph- tee on Dental Informatics has identified four basic goals
ics interchange format); BMP (Windows’ bitmap image for electronic standards in dentistry: (1) interoperability,
file); PNG (portable network graphics); and so on. There also (2) electronic health record design, (3) clinical workstation
are several proprietary formats. “Lossy” and “lossless” com- architecture, and (4) electronic dissemination of dental
pression schemes can be used for saving images, although information.10 The dental profession must continue to pro-
lossless compression is preferred.72 mote DICOM compatibility so that proprietary software and
file types do not hinder communication and risk making
DIGITAL IMAGING AND COMMUNICATIONS data obsolete.
IN MEDICINE
DICOM is a set of international standards established in Diagnostic Tasks in Endodontics
1985 by the American College of Radiology (ACR) and the
National Electrical Manufacturers Association (NEMA)60,205 It is important to analyze the type of sensor used, software,
to address the issue of vendor-independent data formats processing, video card and monitor, and viewing conditions
and data transfers for digital medical images. The ADA has to determine whether the sensor is good for a specific diag-
promoted the interoperability of dental images through the nostic task. Calibration improves diagnostic accuracy.128
efforts of its Working Group 12.1.26. DICOM serves as a Likewise, the use of optimal processing parameters im-
standard for the transferal of radiologic images and other proves image quality to the extent of making a significant
medical information between computers, allowing digital difference in the diagnostic outcome. For instance, density
communication between systems from various manufac- plot analysis was shown to help with endodontic file mea-
turers and across different platforms (e.g., Apple iOS or surements.172 The major advantage of direct digital radiog-
Microsoft Windows).60 The DICOM standard provides for raphy (CCD, CMOS) is that the dose is significantly less
several hundred attribute fields in the record header, which compared with that required for film. The use of DDR,
contains information about the image (e.g., pixel density, therefore, is justified when its performance is comparable to
dimensions, and number of bits per pixel), in addition to that of film with no statistically significant differences.120
relevant patient data and medical information. Although The three types of measurement generally available
earlier versions did not specify the exact order and defini- with digital imaging software are (1) linear measurement,
tion of the header fields, each vendor is required to publish the distance between two points in millimeters (Fig. 2.3);
a DICOM conformance statement, which gives the location (2) angle measurement, the angle between two lines; and
of pertinent data. The big hurdle is to support medical and (3) area measurement, the area of the image or a segment
dental consultations between two or more locations with of the image. Because magnification and distortion errors
different imaging software.60 With DICOM in place, dental play a significant role in the accuracy of two-dimensional
clinicians can change vendors and maintain database in- (2D) radiographic measurement, both film and digital sys-
teroperability. Most software vendors are striving to achieve tems are subject to parallax error. However, a study that
full DICOM compliance, and some have achieved at least compared endodontic file length images of human teeth

A B
Fig. 2.3 A, Certain regions of interest (ROI) can be highlighted with a preset contrast tool that can be moved around the image. B, Preprogramed filters
that enhance sharpness and contrast can be selected to optimize the image acquired. (Courtesy Carestream Dental LLC. Atlanta, GA.)

taken with a custom jig suggested that “measurement error availability of three-dimensional (3D) information, the
was significantly less for the digital images than the film- relatively higher resolution, and a significantly lower dose
based images.”63 This was true even though, as the authors compared to MDCT make CBCT the imaging modality of
pointed out, the measurement differences may not have choice in challenging situations demanding localization
been clinically significant. Sophisticated calibration algo- and characterization of root canals.
rithms are under development, and accurate measurement The adoption of advanced imaging modalities such
of parallel images should be more feasible in the future.41 as CBCT for select diagnostic tasks is becoming popular
with clinicians performing endodontic procedures. Two-
dimensional grayscale images, whether conventional film-
DIAGNOSIS AND HEALING
based or digital, cannot accurately depict the full 3D repre-
Image enhancement of direct and indirect digital radio- sentation of the teeth and supporting structures. In fact,
graphs based on the diagnostic task at hand has been shown traditional images are poor representations of even the
to increase diagnostic accuracy compared to film-based im- pulpal anatomy. They grossly underestimate canal structure
ages, which cannot be enhanced.6,226 Posttreatment endo and often cannot accurately visualize PA changes, especially
dontic evaluation of healing of apical radiolucent areas is a where there is thick cortical bone, as in the presence of
challenge. Early changes indicating healing and bone fill are anatomic obstructions (Fig. 2.4, A). CBCT, however, allows
difficult to detect on conventional or digital radiographs. the clinician to view the tooth and pulpal structures in
However, bone fill can be detected using more sensitive tech- thin slices in all three anatomic planes: axial, sagittal, and
niques, such as digital subtraction radiography (DSR), in coronal. This capability alone allows visualization of PA
which two images, separated in time but acquired with the pathoses and root morphology that was previously impos-
exact same projection geometry and technique factors, can sible to assess (see Fig. 2.4, B and C). Several tools available
be subtracted from one another to tease out subtle changes in CBCT, such as the ability to change the vertical or hori-
in the periodontium and surrounding bone. Subtraction zontal angulation of the image in real time, in addition to
techniques are difficult to carry out in routine clinical prac- thin-slice, grayscale data of varying thicknesses, will never
tice because they are technique sensitive and can yield be available for conventional or even digital radiography.
incorrect information if not performed accurately. Several Furthermore, the use of CBCT data to view the region of
studies have shown the usefulness of subtraction radiogra- interest in three anatomic planes of section at very low x-ray
phy using digital sensors.138,150,231 doses has never been as easy or accessible as it is today.
Microcomputed tomography (micro-CT) has also been
THREE-DIMENSIONAL IMAGING evaluated in endodontic imaging.103,169,170 Comparison of
the effects of biomechanical preparation on the canal vol-
Computed tomography (CT) was introduced by Sir Godfrey ume of reconstructed root canals in extracted teeth using
Hounsfield in the 1970s. Tomography refers to “slice imag- micro-CT data was shown to assist with characterization of
ing,” in which thin slices of the anatomy of interest are morphologic changes associated with these techniques.170
captured and synthesized manually or using an algorithm. Peters et al.169 used micro-CT to evaluate the relative perfor-
CT makes use of automated reconstruction. Medical-grade mance of nickel-titanium (Ni-Ti) instruments after the shap-
CT used a translate-rotate image acquisition scheme as the ing of root canals of varying preoperative canal geometry. A
technology developed, but the modality always resulted in study to examine the potential and accuracy of micro-CT for
higher radiation dose delivery because of redundancy of imaging of filled root canals showed it to be a highly accurate
data capture, in addition to longer scan times with the and nondestructive method for the evaluation of root canal
potential for motion artifact. Multiple detectors and x-ray fillings and its constituents. The qualitative and quantitative
sources were used in later generations of CT units to reduce correlations between histologic and micro-CT examination
scanning times. The increased radiation dose, artifacts from of root canal fillings were high.103 However, it is important to
metallic restorations, cost of scanning, long acquisition note that micro-CT remains a research tool and cannot be
times, and lack of adequate dental-specific software have used for human imaging in vivo.
been drawbacks limiting the use of the technology in den- This chapter discusses the principles, applications, imag-
tistry until recently. The advent of cone-beam volumetric ing attributes, image artifacts, and potential liability of
computed tomography (CBVCT) introduced a faster, low- adopting CBCT technology for endodontic procedures.
dose, low-cost, high-contrast imaging modality that could Given this information, the student of endodontics will
capture information in three dimensions using a limited begin to realize the significant advantages, limitations, and
field of view (FOV). diagnostic and treatment planning capabilities of this
CBVCT, or cone beam CT (CBCT), is a relatively new diag- radiographic imaging modality.
nostic imaging modality that has been recently added to the
endodontic imaging armamentarium. This modality uses a
cone beam instead of a fan-shaped beam in multidetector Principles of Cone Beam
computed tomography (MDCT), acquiring images of the
entire volume as it rotates around the anatomy of interest.
Computed Tomography
Compared with MDCT images, CBCT offers relatively high- Two important parameters of cone beam imaging are
resolution, isotropic images, allowing effective evaluation described in the following sections:
of root canal morphology and other subtle changes within
the root canal system. Even though the resolution is not as n Voxel size
high as that of conventional radiographs (18 microns), the n Field of view (FOV)

A B

C
10 mm 5 mm 2 mm 0.076 mm
Fig. 2.4 This case demonstrates the difficulty in assessing lesions in the mandibular posterior region when there is a dense cortex. A, This well-angulated
periapical radiograph shows a normal periapical region associated with the mandibular left second molar, for which the patient has presented for evalu-
ation and possible retreatment. B, The CBCT corrected sagittal, coronal, and axial reconstructed multiplanar views, (left to right, sagittal, coronal, and
axial views) show previous endodontic treatment, with a 6 mm diameter radiolucency with a well-defined, mildly corticated border, centered over a point
on the buccal aspect of the root, 2 mm coronal to the apex; these are features consistent with an apical rarefying osteitis. C, The ray sum images of the
sagittal view, where the image is “thinned” by decreasing the number of adjacent voxels using postprocessing software, simulates a curvilinear projec-
tion, showing diminishing superimposition (left to right, image layer of 10 mm, 5 mm, 2 mm, and 0.076 mm). (Data acquired and reformatted at 0.076 mm
voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

VOXELS AND VOXEL SIZES

Voxels are cuboidal elements that constitute a 3D volume,
unlike pixels, which are 2D. Data are acquired and repre-
sented in three dimensions using voxels. Unlike with
MDCT, typically used in medicine, cone beam units ac-
quire x-ray information using low kV and low mA expo-
sure parameters in a single pass from 180 to 360 degrees
of rotation around the anatomy of interest. Medical scan-
ners use higher voltages of 120 kV or more and a current
of about 400 mA. Several units used in maxillofacial
imaging use significantly lower exposure parameters
(Figs. 2.5 to 2.7). The x-ray dose for all cone beam units is
significantly lower than the dose received from a MDCT
unit. Image attributes are also different in that volumes
are reconstructed from isotropic voxels; that is, the images
are constructed from volumetric detector elements that
are cubical in nature and have the same dimensions of
length, width, and depth. These voxel sizes can be as small
as 0.076 to 0.6 mm.139 By comparison, MDCT slice data
are 0.5 mm to 1 cm thick. Fig. 2.8 illustrates the difference
between a pixel and a voxel, the difference between an
anisotropic pixel of MDCT and an isotropic pixel (voxel) Fig. 2.5 i-CAT unit. (Courtesy Imaging Sciences International, Hatfield, PA.)
of CBCT, and how the pixel data are acquired from both
modalities.
The patient is positioned on a gantry in an MDCT unit, as images are acquired, thus shortening the acquisition
and images are acquired multiple slices at a time, which time. This results in significantly higher absorbed x-ray
prolongs the acquisition time. The number of slices ac- doses for the patient. A typical CBCT examination would
quired is a direct function of the sensor array configuration. expose the patient to only about 20 to 500 mSv in a single
Spiral CT uses continuous translator motion of the gantry study, whereas a typical medical examination of the head

A B

Fig. 2.6 A, Planmeca ProMax 3D. B, J. Morita Veraviewepocs 3D. (A, Courtesy Planmeca Oy, Helsinki, Finland. B, Courtesy, JMorita USA, Irvine, CA).

A B
Fig. 2.7 A, CS 9000 3D and CS 8100 extraoral imaging systems. B, Morita Accu-i-Tomo 170. (A, Courtesy, Carestream Dental LLC, Atlanta, GA;. B, Courtesy
J Morita USA, Irvine, CA).

B
would approach 2100 mSv because the image data are FIELD OF VIEW
gathered one section at a time. Therefore, soft-tissue imag-
The FOV (Figs. 2.9 and 2.10) ranges from as small as a por-
ing is better with MDCT because the signal intensity
tion of a dental arch to an area as large as the entire head.
is higher. However, this is not a requirement for dental
The selection of the FOV depends on several factors. Among
diagnostic tasks because hard tissue visualization is more
the most important are the following:
important. Consequently, CBCT data have a much higher
resolution than MDCT data for hard tissue visualization n Diagnostic task
because of the smaller voxel sizes that medical-grade n Type of patient
scanners are incapable of achieving at a significantly lower n Spatial resolution requirements
dose. Increased noise is observed as a result of volumetric
acquisition, but the SNR is maintained at a desirable level Diagnostic Task
that facilitates adequate diagnosis based on hard tissue The diagnostic task is the single most important determi-
signals. nant of the FOV in any imaging study. Based on the outcome

A
Pixel Voxel

X-ray source
X-ray source

“Fan” of x-rays

“Cone” of x-rays

B
Detector C Detector
Fig. 2.8 A, Left, Drawing represents a pixel (picture element), the image capture and display element of any traditional digital image displayed on the
computer. Shades of gray or color are displayed in these pixels to represent a 2D image. Right, Drawing represents a voxel (volume element). Voxels in
CBCT are isometric and have the same dimension or length on all sides. They are very small (from 0.076 to 0.6 millimeters) and are the capture elements
for cone beam imaging devices. Principles of conventional fan beam and cone beam computed tomography are presented in B and C, respectively.
(B and C, From Babbush CA: Dental implants: the art and science, ed 2, St Louis, 2011, Elsevier/Saunders.)

Fig. 2.10 Image of entire head (17 3 23 cm) from a large FOV
Fig. 2.9 Multiplanar and 3D color reconstructed views of the mandibu- unit. (Image acquired with iCAT unit [Imaging Sciences International,
lar quadrant taken on a CBCT machine with a volume size of 37 3 Hatfield, PA].)
50 mm. (Data acquired and reformatted at 0.076 mm voxel size using a
CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

of the clinical assessment, history, and evaluation of previ- endodontic purposes, a limited FOV can be used if no signs
ous and other available imaging studies, a segment of the or symptoms of systemic conditions are reported or noted.
jaw or a larger area may need to be imaged using an appro- Under no circumstances should a screening study be done
priate FOV. If systemic conditions or generalized disorders using a large FOV in the absence of signs and symptoms
are suspected, a larger FOV is sometimes required. For most justifying the procedure. Several multifunctional cone beam

units are available that allow the clinician to acquire several of 76 microns, whereas the CS 9300 can resolve down to
image types. Image quality has a direct impact on the diag- 90 microns, with a range extending to 500 microns for larger
nostic outcome; therefore, the choice of a FOV should be FOV studies. Likewise, the Morita 3D Accuitomo 80 (J. Morita
made carefully. Fig. 2.11 illustrates the advantages of using USA, Irvine, CA) generates isotropic voxels of 80 microns.
multiple image types for an endodontic case. Although not necessary for use in every case, this technology,
Additional benefits of CBCT imaging software include al- when appropriate, improves visualization and ultimately
lowing the clinician to format the volume to generate an leads to better care in select situations. A record of exposure
image that looks like a panoramic radiograph. Conventional and doses must be maintained for each patient.
panoramic machines, although not commonly used by endo-
dontists, use the focal trough, or zone of sharpness, to posi- Type of Patient
tion patients so as to minimize distortion along multiple axes. Patient size and thus the amount of regional anatomy cap-
All inherent problems associated with panoramic imaging, tured in the study also help determine the FOV. The smallest
including distortion, magnification, blurring, ghost shad- possible FOV must be chosen for the task at hand. Just be-
ows, and other artifacts, can be expected on the resulting cause a clinician owns a cone beam machine does not mean
image if patient positioning is not accurate. With CBCT, such that every patient should be exposed to a cone beam
artifacts are not generated, resulting in a distortion-free pan- study.140 If previous studies are available, they need to be
oramic reconstruction (Fig. 2.12). However, it must be noted evaluated first in a recall patient. Use of imaging in children
that CBCTs should not be generated in patients requiring a must be minimized. Cone beam units with smaller FOVs
panoramic radiograph alone because of dose concerns. can somewhat limit the radiation dose to critical organs
Newer hybrid units, such as the CS 9300 3D Extraoral and tissues of the head and neck in these cases.
Imaging System (Carestream Dental, Atlanta, GA), have a Several CBCT units allow the use of a wheelchair to posi-
wide range of FOV choices for a variety of diagnostic tasks, in tion special needs patients or a regular chair for patients to
addition to a conventional panoramic imaging option sit down during image acquisition. The potential to reduce
(Fig. 2.13). The CS 9000 unit offers the lowest voxel size motion artifacts may be an advantage (Figs. 2.14 and 2.15).

A B

Fig. 2.11 A, Panoramic 2D image exposed with the

JMorita Veraviewepocs 3D for evaluation of the mandibu-
lar left central incisor. Other radiographic findings also
were revealed, including the horizontal bony impaction of
the mandibular right third molar and a possible lesion of
endodontic origin associated with the endodontically
treated maxillary left second molar. Data available from
the scan allowed a 3D reconstruction to be made for areas
of concern. B, Periapical radiograph of the maxillary left
second molar on the same patient revealed a periapical
area of low attenuation in the region of the periapex of
the mesiobuccal root. In this case, also, changes could be
evaluated in greater detail with CBCT imaging. C, CBCT of
the maxillary left second molar revealed detailed periapi-
cal and periradicular changes in all three orthogonal
planes of the section, specifically illustrating the lesion of
endodontic origin associated with the mesiobuccal root.
Examination of the width of the mesiobuccal root in both
the axial and coronal views (buccolingually) showed that
the mesiobuccal root possibly had two canals and that
only a single canal was treated during the initial endodon-
tic therapy. (Data acquired and reformatted at 0.076 mm
voxel size using a CS 9000 3D unit [Carestream Dental,
C Atlanta, GA].)

A B

C D
Fig. 2.12 A, This reconstructed panoramic image from CBCT data approximates the view one would see with a conventional panoramic radiograph. It
is somewhat difficult to see the lesion on the maxillary left first molar. B, This thin-slice pseudopanoramic image (0.01 mm) shows the lesion without
most of the anatomic superimposition. These slices of the maxillary left first molar show the lesion in sagittal (C) and coronal (D) views, confirming the
features seen in the pseudopanoramic view.

Fig. 2.13 CS 9300 3D Extra-Oral Imaging System. (Courtesy Carestream

Dental LLC, Atlanta, GA.)

Fig. 2.14 Veraviewepocs 3D R100. (Courtesy JMorita USA, Irvine, CA.)

International, Irvine, CA), default to a 0.4 mm voxel size.

This voxel size is inadequate for high spatial detail. However,
these units often have a voxel size selection option that allows
smaller voxel sizes to be used during the image acquisition.
The absolute maximum voxel size for endodontic imaging
should be 0.2 mm.44 Units typically use voxel sizes of 0.075
to 0.16 mm for their native image capture (Fig. 2.16).

Imaging Tasks Improved or

Simplified by Cone Beam
Volumetric Computed
Tomography
The Executive Opinion of the American Academy of Oral
and Maxillofacial Radiology and, later, the position paper
on the use of CBCT in endodontics jointly developed by the
American Association of Endodontists (AAE) and the
American Academy of Oral and Maxillofacial Radiology
(AAOMR), list indications for potential use in selected cases,
including evaluation of the anatomy and complex mor-
phology, differential diagnosis of complex pathoses with
certain qualifiers, intraoperative or postoperative assess-
ment of endodontic treatment, dentoalveolar trauma, re-
sorption, presurgical case planning, outcomes assessment,
and dental implant case planning.1 Use of CBCT must be
determined on a case-by-case basis only. These indications
Fig. 2.15 CS 8100-3D. (Courtesy Carestream Dental LLC, Atlanta, GA.) do not in any way mandate the use of CBCT for every case
that falls into one of the preceding categories. For endodon-
tic treatment and assessments, there are at least five
Spatial Resolution Requirements primary imaging tasks in which CBCT scans have a distinct
All endodontic imaging procedures require high spatial res- advantage over traditional 2D radiographs. These tasks
olution. Assessment of canal structure, canal length, and include the evaluation of the following factors:
lesions of endodontic origin (LEOs)189 showing apical
change, in addition to an understanding of possible retreat- 1. Differential diagnosis
ment cases, are important tasks requiring minute detail. If a. Lesions of endodontic origin
CBCT is used, the data acquisition should be performed at b. Lesions of nonendodontic origin
the smallest voxel size: the smaller the voxel size, the higher 2. Evaluation of anatomy and complex morphology
the spatial resolution. Many of the larger stand-alone a. Dental anomalies
cone beam machines, such as the i-CAT (Imaging Sciences b. Root canal system morphology

A B
Fig. 2.16 A, Axial slice from data obtained with a 0.4 mm voxel size. B, Compare the trabecular pattern and outline of the mental foramina to the same
location in an axial slice from data obtained with a 0.16 mm voxel size.

3. Diagnosis of endodontic treatment failures literature points to a significant chance that lesions of the
4. Intraoperative or postoperative assessment of end- tooth-supporting structures are nonendodontic in origin,
odontic treatment complications such as PA cemento-osseous dysplasia; central giant cell
a. Vertical root fractures granulomas; lateral periodontal cyst, simple bone cysts;
b. Overextended root canal obturation material odontogenic cysts, tumors, or malignancies; and neuro-
c. Separated endodontic instruments pathic pain (Figs. 2.17 and 2.18).39,68,100,168,179,180
d. Calcified canals Neuropathic orofacial pain or atypical odontalgia (AO),
e. Perforations also known as chronic continuous dentoalveolar pain
5. Presurgical treatment planning (CCDAP)153 and persistent dentoalveolar pain (PDAP),98 is re-
6. Dentoalveolar trauma lated to a tooth, teeth, or pain at an extraction site where no
7. Internal and external root resorption clinical or radiographic pathosis is evident. Two systematic
8. Endodontic treatment outcomes assessment reviews of AO showed the incidence of persistent pain of
9. Dental implant case planning more than 6 months’ duration after nonsurgical and surgi-
10. 3D guided endodontics cal endodontic treatment, excluding local inflammatory
causes, was 3.4%.151 The pathophysiology of this pain is
DIFFERENTIAL DIAGNOSIS uncertain, but it is hypothesized to involve deafferentation
of peripheral sensory neurons in predisposed patients. The
Lesions of Endodontic Origin diagnosis of AO is challenging and depends on the patient
Clinical endodontic diagnosis relies on subjective and objec- history and clinical examination findings in addition to the
tive information collected during patient examinations. absence of radiographic findings. In some cases, the symp-
Diagnosis of the pulpal status of the teeth can sometimes be toms from AP and AO are closely related. Pigg et al.173
challenging if adequate radiographic information is un- conducted a study of 20 patients with AO. All the patients
available. It is fundamental to understand that LEOs arise had at least one tooth in the region of discomfort that had
secondary to pulpal breakdown products and form adjacent undergone invasive treatment; 21 of 30 teeth had under-
to canal portals of exit.183,190 These radiolucent lesions, gone endodontic treatment. These researchers found that
formed as a result of loss of bone mineralization, can and 60% had no PA lesions, and among those who did, CBCT
do form three dimensionally anywhere along the root sur- showed 17% more PA lesions than conventional radiogra-
face anatomy.184 A 30% to 40% mineral content loss is phy. This study demonstrated that CBCT may be a useful
needed for these lesions to be visualized on conventional supplement to 2D radiography (see Fig. 2.18).
radiographs.137 Furthermore, the thickness of the corti- The 3D radiographic appearance of a PA lesion provides
cal plate covering the lesion may significantly affect the additional information about the lesion’s relationship to the
radiographic appearance of the lesion on a conventional tooth and other anatomic structures (e.g., the vascular
image.229 DSR has been observed to increase diagnostic bundle) and about the aggressiveness of the lesion. This
capability with observers identifying incipient PA lesions information, along with pulp sensitivity testing, is useful for
in more than 70% of the cases.137 adequate treatment planning and management of these
Before the advent of CBCT, clinicians were unable to rou- conditions (see also Chapter 3).
tinely visualize the presence, specific location, and exten-
siveness of PA bone loss using conventional radiography.127 EVALUATION OF ANATOMY AND COMPLEX
This was especially true in areas with superimposition of
MORPHOLOGY
anatomic structures. Visual obstruction from anatomic fea-
tures, such as buccal bone and the malar process over the The precise location and visualization of dental anomalies,
apices of maxillary roots, simply “disappears” when the root morphology, and canal anatomy are vastly improved
examiner can scroll through the slices of the bone from with CBCT data. Root curvature, additional roots, and
facial to palatal in 0.1 mm sections while also changing anomalies within the canals themselves (e.g., obstructions,
axial orientations. CBCT showed significantly higher rates narrowing, bifurcation) are made more apparent when all
of detection of PA lesions in maxillary molars and premo- three anatomic planes of section are available for review,
lars compared to PA radiography.129 CBCT also showed a especially with the capability of narrowing the slice thick-
significantly higher diagnostic accuracy to detect apical ness to as little as 0.075 mm. Visual obstruction from ana-
periodontitis (AP) when compared to PA radiographs using tomic features such as buccal bone and the malar process
human histopathology as the gold standard.108 over the apices of maxillary roots simply will “disappear”
In a comparative investigation of the use of CBCT and PA when you can scroll through the slices of the bone from
radiography in the evaluation of the periodontal ligament facial to palatal in 0.076 mm sections while also changing
(PDL), Pope et al.176 showed that necrotic teeth examined axial orientations (Fig. 2.19).
with CBCT had widened PDLs but 60% of vital teeth showed
a PA widening of 0.5 mm or more. They called for further Dental Anomalies
investigation to determine whether health and disease can The use of CBCT technology has been reported in the diag-
be appropriately judged using CBCT in epidemiologic inves- nosis and treatment planning of various dental anomalies
tigations. See Chapter 3 for more information. (e.g., dens invaginatus) that often have complex morpho-
logic presentations.152 The prevalence of dens invaginatus
Lesions of Nonendodontic Origin was as high as 6.8% in the adolescent Swedish population
Differential diagnosis of PA pathology is crucial to endo studied.21 The complex nature of the anomaly presents a
dontic treatment planning. Substantial evidence in the diagnostic challenge when conventional radiographs are

B C

D
Fig 2.17 Lateral periodontal cyst. A 12-year-old male presented for orthodontic consultation with an elevated lesion in the maxillary right anterior region
that was fluctuant under pressure; the patient was referred for endodontic evaluation and radiographic assessment. The pulp vitality was normal for the
maxillary anterior dentition. A preoperative CBCT of the anterior maxilla was exposed (A, pseudopanoramic reformation; B, 3D surface reformation;
C, cross-sectional reformation of the maxillary right lateral incisor) showing a unilocular/ovoid area of uniform low density that measured approximately
18.0 mm 3 15.0 mm. D, Axial reformation showing a partially well-defined, noncorticated border mesial to the canine and a poorly defined border be-
tween the distal of the right lateral and central incisor. Surrounding tissues showed locally destroyed buccal and palatal cortical plates of the right anterior
side of the maxilla with 6 mm of expansion of the buccal and palatal plates in the area between the canine and lateral incisor. Roots of the canine and
lateral incisor are displaced mesially and distally, respectively. There was a 3 to 5 mm thickening of the sinus membrane of the overlying floor of the max-
illary sinus. Seven months after surgical intervention, the patient was asymptomatic and a follow-up CBCT study was acquired, showing normal healing.

E F

G
Fig 2.17, cont’d E, 3D surface. F, Cross-sectional. G, Axial reformation. (Courtesy Dr. Rina Gonzalez-Albazzaz and Dr. Barry Pass.)

A B C
Fig. 2.18 A 62-year-old female was referred for evaluation and possible treatment for persistent dentoalveolar pain (PDAP) in the maxillary left region.
The patient could alleviate this condition by placing a moist cotton roll in the adjacent vestibule to prevent the buccal mucosa from contacting the
alveolus supporting the maxillary teeth in this area. This condition began after a history of local anesthetic administration, persisted for 1 year, and led
to three successive new crowns and endodontic treatment on the “offending tooth,” in an effort to remedy the condition without improvement. The
response to endodontic tests, TMJ, and myofascial evaluations were normal. Application of topical xylocaine resulted in cessation of pain for 15 min-
utes. A, A PA radiograph showed a root-treated, maxillary left first molar with no apparent radiographic lesion. B, A limited FOV CBCT of the maxillary
left posterior was acquired. The corrected sagittal view showed an approximately 4 mm, well-defined, ovoid, mildly corticated area of low attenuation
(radiolucent) centered over the apex of the mesiobuccal root and extending to the junction of the middle and apical third of the mesiobuccal root
(yellow arrow). There was mild mucositis (green arrow). C, There was a previously untreated mesioaccessory canal (yellow arrow) and mild mucositis. A
diagnosis of neuropathic pain and a chronic apical periodontitis was made. Daily application of topical ketamine, gabapentin, and clonidine was pre-
scribed. Endodontic revision of the maxillary left first molar was performed 3 months after the patient was stabilized with the topical medications. (Data
acquired and reformatted at 0.076 mm voxel size using a CS 9000 3D [Carestream Dental, LLC. Atlanta, GA].)

A B

Fig. 2.19 This patient was referred

for evaluation and possible treatment
after emergency pulp extirpation per-
formed by others. A, This PA radio-
graph shows that the location of the
physiologic terminus (yellow arrow)
and radiographic apex (blue arrow)
did not appear to coincide within the
normal range. B, Contemporaneous
CBCT sagittal reformation shows the
anomalous location of the physio-
logic terminus (yellow arrow) and ra-
diographic apex (blue arrow). C, Pres-
ence of a mesioaccessory canal with
isthmus (blue arrow) and (D) an oval-
shaped canal (yellow arrow) is appar-
ent. (Courtesy Dr. Anastasia Mischenko,
Chevy Chase, MD. Data acquired and
reformatted at 0.076 mm voxel size us-
ing a CS 9000 3D unit [Carestream
C D Dental, Atlanta, GA].)

used.160 In case reports in which CBCT was used for diagno- for identification of the root canal morphology,145 and CBCT
sis and treatment planning, treatment options included studies report variation in the root canal morphology among
conservative endodontic treatment of the invagination, various ethnic groups.146,204,236,238 Accuracy of CBCT imag-
surgical treatment of the PA pathology, and complete revas- ing for detection of second mesiobuccal canal in maxillary
cularization of the dens after removal of the invagination molars has been shown to be 96%, and the prevalence of
(Fig. 2.20).144,222 midmesial canals in mandibular molars was found to be
16.4%.203
Root Canal System Morphology
As the adage goes, nature seldom makes a straight line and DIAGNOSIS OF ENDODONTIC TREATMENT
never makes two of the same. This statement is dramatically
FAILURES
illustrated in the evaluation of root canal system morphol-
ogy. With ever-present unusual and atypical root shapes and The failure of previous endodontic therapy can be attrib-
numbers, there is sometimes a need to look further than uted to various factors, such as procedural errors, missed
what a clinician can see or imagine with 2D radiography canals, or persistent PA pathosis. Knowledge of the cause of
(Fig. 2.21). Variations in root canal morphology have been failure is pertinent to the treatment of these cases because
studied using various in vitro techniques.70,174,220,221 The re- it allows the cause to be adequately rectified. With the ad-
sults of these studies point to the fact that there is significant vent of CBCT, in select cases of retreatment in which the
variation in the root canal morphology among various eth- cause of failure is otherwise undetectable, adequate infor-
nic population groups.8,90,91,149,224 CBCT has been reported mation may be collected to apply to the treatment plan. Use
to be comparable to canal staining and clearing techniques of CBCT in these situations will aid in treatment planning

A B

Fig. 2.20 A, Dens en dente of the mandibular left second bicus-
pid; coronal slice. B, Coronal view. C, Panoramic reconstruction
from CBCT. D, Sagittal view. (Data acquired and reformatted at
0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, D
Atlanta, GA].)

A B
Fig. 2.21 A, Mandibular left second molar referred for endodontic evaluation and possible treatment. This 2D radiograph reveals significant pulp
stones and canal calcification developing not only in the coronal aspect of the root canal system, but also extending down the visible distal canal. The
apical third of the canal system appears unusual and dilacerated. Cone-beam computed tomography (CBCT) would be beneficial in visualizing the root
canal anatomy, to create the ideal endodontic access. B, Single slice of the CBCT image for the same tooth. Information about the direction of the
root canal anatomy is provided in all three planes of the section: axial, coronal, and sagittal. Interestingly, the axial slice shows that the mesial lingual
root actually traverses buccally as it approaches its terminal extent. This is valuable information for the clinician before the entire root canal system is
cleaned and shaped; it may also establish a higher degree of treatment predictability.

A B C
Fig. 2.22 This 38-year-old female patient presented for evaluation and treatment of a symptomatic mandibular right second molar, which had been
endodontically treated more than 10 years previously. This tooth was sensitive to percussion and biting forces; periodontal findings were normal.
Microscopic examination of the exposed dentin was negative for a vertical fracture. A, The PA radiograph showed the previous endodontic treatment; a
post present in the distal canal; and an approximately 5 mm diameter, unilocular, well-defined area of uniform low density centered at the periapex of the
distal root—features consistent with an apical periodontitis. Contemporaneous (B) CBCT sagittal and (C) axial reformations revealed a previously un-
treated distobuccal canal (yellow arrow). (Data acquired and reformatted at 0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

and improve outcomes (Fig. 2.22).109 A study by Rodriguez confined to the roots, making it difficult to visualize the
et al. showed that the endodontic retreatment strategies fracture. Visualizing the fracture on a conventional radio-
were altered in 49.8% of cases after CBCT images were in- graph is possible when the x-ray beam is parallel to the
cluded for diagnosis by general dentists and endodontists.181 plane of the fracture.182 Challenges in diagnosis with re-
Use of CBCT in evaluation of previously endodontically gard to the extent and exact location of the fracture often
treated teeth aids in visualizing missed canals, canal devia- lead to unwarranted extraction of teeth. Since the intro-
tions, resorption, procedural errors such as perforation, duction of CBCT to dentistry, various reports of the applica-
and other pathology. tion of the technology to detect vertical root fractures have
The technology is most useful in detecting uninstrumented been published. The reported sensitivity for detection of
and unfilled canals, extension of the root canal filling, and VRFs has ranged from 18.8% to 100%136; by comparison,
the presence and extent of periradicular bone loss. The inci- conventional radiographs have a reported sensitivity of
dence of missed canals in failed endodontic treatments were approximately 37% (Fig. 2.23).62,95 CBCT has been used to
found to be 23.04% with the highest incidence in upper visualize VRFs in controlled clinical studies in which clinical
molars. These teeth had 4.38 more likelihood of having a diagnosis was difficult.62 VRFs were successfully detected
PA lesion.109 The sensitivity of CBCT and PA radiographs for at a spatial resolution ranging from 76 to 140 microns.
diagnosing strip perforations in root-filled teeth has been However, only a limited number of units provide such high
shown to be low, although CBCT showed a significantly resolution. A comparison of various CBCT units for the
higher sensitivity when compared to PA radiographs.194 detection of VRFs demonstrated that the units with flat
Radiopaque filling materials in the root canals of endodonti- panel detectors (FPDs) were superior to the image intensifier
cally treated teeth can produce streak artifacts, which tube (IIT)/CCD–based detectors; the smaller FOV and the
can mimic fracture lines or perforations.194,237 Use of lower ability to view axial slices also improved detection of VRFs.96
exposure parameters and nonmetallic fiber posts can sig- Continued improvement of sensor technology, including
nificantly reduce these artifacts, allowing for an improved the use of FPDs, has resulted in enhanced resolution. Voxel
diagnosis.59 dimensions are smaller in these units. Detection of vertical
root fractures with thickness ranging from 0.2 to 0.4 mm
Intraoperative or Postoperative was found to be more accurate with CBCT than with digital
radiography.155,161 The presence of root canal filling in
Assessment of Endodontic the teeth lowers the specificity of CBCT in detecting vertical
Treatment Complications root fractures95,96,111; this has been attributed to the radi-
opaque material causing streak artifacts that mimic fracture
VERTICAL ROOT FRACTURES lines.237
Zhang et al. reported a low sensitivity of 33.3% for detec-
Vertical root fractures (VRFs) that run along the long axis of tion of subtle vertical root fractures in a clinical study. How-
a tooth are often difficult to diagnose clinically. The preva- ever, the study showed the presence of vertical bone loss in
lence of VRF in endodontically treated teeth has been a high number of the cases.235 Bone loss pattern around
reported to range from 8.8% to 13.4%.77,207,233 These frac- teeth with vertical root fractures viewed on CBCT images
tures typically run in the buccolingual direction and are may assist clinicians in diagnosis of VRF.211

A B

C
Fig. 2.23 Root fracture in an endodontically obturated maxillary right central incisor. A, Axial view with artifacts from a highly attenuating (opaque)
obturant. B, View without artifacts from obturant. C, Oblique parasagittal view. D, Paracoronal view. (Data acquired and reformatted at 0.076 mm voxel
size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

OVEREXTENDED ROOT CANAL OBTURATION

variations of the IAN bundle, including the anterior loop and
MATERIAL
bifid mandibular canals.45 Kovisto et al.116 used CBCT mea-
CBCT scans provide the opportunity to map endodontic surements from 139 patients to show that the apices of the
treatment complications through the examination of 3D mandibular second molar were closest to the IAN bundle. In
representations of the teeth and supporting structures in females, the mesial root of the second molar was closer than
different planes. Few high-level studies related to the effects in males, and the distances in all roots measured increased
of endodontic treatment complications have been pub- with the age of the patient. There was a high correlation be-
lished in the endodontic literature.206 However, it is gener- tween the measurements from left to right side in the same
ally recognized that the overfilling of the root canal, caus- patient, and an average distance of 1.51 to 3.43 mm in
ing damage to vital structures such as the inferior alveolar adults.116 Procedures involving the mandibular second molar
neurovascular (IAN) bundle (Fig. 2.24) or the maxillary were most likely to cause nerve damage.126 Further research
sinus, can cause significant morbidity.34,35,76,80 is required to clarify the risks and benefits of CBCT when
Endodontic therapy undertaken in close proximity to the endodontic treatment is contemplated on teeth with a proxi-
IAN bundle should receive special attention because direct mal relationship between the IAN and root apices. Porgrel
trauma, mechanical compression, chemical neurotoxicity, treated 61 patients with involvement of the IAN bundle after
and an increase in temperature greater than 10°C may cause root canal therapy during a 7-year period. Eight patients were
irreversible damage.65,85,88,214 Scolozzi et al. reported that asymptomatic; 42 patients were seen for mild symptoms or
sensory disturbances can include pain, anesthesia, paresthe- were examined more than 3 months postoperatively, with
sia, hypoesthesia, and dysesthesia.191 The IAN bundle is lo- only 10% experiencing improvement. Five patients under-
cated in the cribriform bone-lined mandibular canal and went surgical treatment before 48 hours elapsed and recov-
courses obliquely through the ramus of the mandible and ered completely. Six patients underwent surgery between
horizontally through the mandible body to the mental fora- 10 days and 3 months, with four experiencing partial recov-
men and the incisive foramen.11 There are many anatomic ery; the remaining two had no improvement.175

A B

C D E
Fig. 2.24 This 64-year-old male patient presented with sensitivity when biting on the mandibular left second molar. The history included endodontic
revision more than 6 months earlier and subsequent transient paresthesia and dysesthesia along the distribution of the inferior alveolar nerve, which
persisted for 1 week after the retreatment. Epicritic and protopathic sensibility was normal. The results of periodontal probing, staining and microscopic
examination of the exposed root surface at the sulcus were normal. A, Initial PA radiograph showed the approximate location of excess radiopaque
material, a feature consistent with extruded root canal sealer (yellow arrow). B, Contemporaneous CBCT corrected sagittal reformation shows approxi-
mate length of extruded material, measuring 3.4 mm (yellow arrow). C and D, Corrected cross-sectional reformation shows the foreign material interior
to the inferior alveolar canal (yellow arrow), an area of low attenuation extending from the apex superiorly to an area near the alveolar crest (blue arrow),
and erosion of the lingual endosseous surface. E, The same feature was shown in the corrected axial view (yellow arrow), bisected by a dark line extend-
ing from the obturant to the surface of the root—features suggestive of a vertical fracture. Examination of the extracted tooth revealed a vertical fracture
at the lingual aspect of the distal root. (Data acquired and reformatted at 0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

New imaging technologies, such as high-resolution mag- exposure of a CBCT image volume should be considered. It
netic resonance imaging (MRI-HR) and magnetic reso- is generally accepted that immediate surgical debridement
nance neurography (MRN), promise to improve isolation of should be attempted to maximize recovery.65,177 With the
the IAN from the neighboring artery and vein contained introduction of MRI algorithms for dental diagnostic pur-
within the inferior alveolar bony canal. MRN studies have poses, it is expected that this imaging modality will be in-
documented the ability to demonstrate nerve continuity creasingly used in diagnostic and treatment planning. MRI
and localize extraneural nerve compression before surgical has the capability to demonstrate vascularity to the tooth
nerve exploration. Postoperative PA radiographs should be of interest, in addition to the presence of inflammatory
exposed on the day of endodontic treatment completion or exudates in the apical regions, without exposing the patient
a suspected iatrogenic event, and any suspected compro- to ionizing radiation. Receiver coils are being developed
mise of the IAN bundle or other vital structures should be to enhance the image quality of maxillofacial and dental
evaluated immediately. In all cases in which trauma to the magnetic resonance studies.
IAN bundle is suspected from PA or panoramic radiography The accidental introduction of root canal instruments,
or by the report of symptoms consistent with nerve injury, irrigating solutions, obturation material, and root tips into

the maxillary sinus has been reported. Serious conse-

quences associated with the intrusion of foreign bodies into
the maxillary sinus include pain, paresthesia, and aspergil-
losis, a rare but well-documented complication of endodon-
tic treatment.24 Guivarc’h et al. reported that the overex-
tension of heavy metal–containing root canal sealers, such
as zinc oxide eugenol cement, may promote fungal infection
in immunocompromised patients, leading to bone destruc-
tion and damage to adjacent structures. This case report
described the use of CT to assess the patient before surgery
and at 6 months.89 The use of CBCT as an aid in the local-
ization and retrieval of an extreme overextension of ther-
moplasticized injectable gutta-percha into the sinus and
contiguous soft tissues has been described by Brooks and
Kleinman.37
A B
SEPARATED ENDODONTIC INSTRUMENTS
Instrument fracture can occur at any stage of endodontic
treatment, and in any canal location. The incidence of this
complication, reported in clinical studies on a per canal or
per tooth basis, ranges from 0.39% to 5.0%.56,157 Molars
are predominantly affected by instrument fracture, with
the highest incidence found in the apical third of mandibu-
lar molars.7,52,123,147
A systematic review and meta-analysis showed that when
endodontic treatment was performed at a high technical
standard, instrument fracture did not significantly reduce
the prognosis. More specifically, when no initial radiographic
PA lesion was present, 92.4% of cases remained healthy;
when a PA lesion was present initially, 80.7% of PA lesions
showed radiographic healing. However, the presence or
absence of periradicular lesions on preoperative and postop-
erative examinations was based on planar radiographic as- C D
sessments, which calls these findings into question.156
Fig. 2.25 Unexpected torsional and flexural failure of endodontic in-
Other studies showed that the chances of endodontic fail- struments can occur during instrumentation. A, PA radiograph shows
ure increased if the canal system could not be thoroughly a separated file (yellow arrow) located at the midroot of the mandibular
disinfected, if a periradicular periodontitis was present, or if left lateral incisor in a patient referred for revision treatment. B, To aid
technical standards were compromised.51,110,198,200 Use of development of a retreatment strategy, CBCT was used to localize the
CBCT to triangulate the retained instrument and assess the instrument (yellow arrow) in the lingual canal, with identification of the
buccal canal (green arrow) to facilitate bypassing the instrument and
canal shape, especially in cases in which the operating (C), subsequent removal. D, Obturation was completed without com-
microscope does not allow direct visualization, can be help- plication. (Data acquired and reformatted at 0.076 mm voxel size using a
ful in formulating a removal strategy. If the fractured instru- CS 9000 3D unit [Carestream Dental, Atlanta, GA].)
ment is lodged in the lingual aspect of a ribbon-shaped canal,
for example, an instrument may be inserted toward the buc-
cal to bypass and remove the imbedded instrument without
forcing the fragment further apically. Without the use of nation’s 65-year-old and over cohort will grow to 81 mil-
CBCT, intracanal instruments can be reliably removed or lion in 2050, up from 37 million in 2005.171 This aging
bypassed in 85.3% of cases if straight-line access is possible; population will present increasing challenges for dental
however, reliable removal or bypass is possible in only 47.7% clinicians because calcification of the root canal system in-
of cases if the instrument is not visible (Fig. 2.25).147 When creases as part of the natural aging process,86 possibly lead-
a separated instrument is lodged in the apical third of a root ing to more untreated canals that may serve as a niche for
canal, the chances of retrieval are the lowest, but the apical microorganisms.28,104 Pulp chambers in the crown of the
terminus may be adequately sealed by treatment of an anas- tooth decrease in size, forming more rapidly on the roof and
tomosing canal, if present.79 The possibility of instrument floor of posterior teeth.219 Typically, root canals calcify
removal based on CBCT triangulation has not been published at the coronal aspect first, with decreasing calcification as
to date. the canal travels apically. Magnification and illumination
are essential tools for the identification and treatment of
calcified canals, but CBCT can assist in the perioperative
CALCIFIED CANALS
treatment of such conditions.23 Preoperative assessment of
According to the Pew Research Center, 10,000 US individ- calcified teeth using CBCT can suggest the best tactic for
uals will reach the age of 65 every day until 2030, and the locating calcified canals in the chamber floor and roots

using software-based measurement tools. The insertion of follows, or even observe which root or roots are involved.
radiopaque markers, such as instruments or obturation Presurgical confusion is resolved with cone beam imaging.
material, can facilitate reliable canal localization using Multiplanar views allow the clinician to see the defect and
available multiplanar reformations. The increased sensitiv- suspected causes from the axial, sagittal, and coronal aspects;
ity and specificity provided by CBCT can also assist in the 3D grayscale or color imaging helps the clinician visualize the
determination of the PA status of calcified root canals that entire defect before the incision is made. This is an immense
may not require measures that can lead to procedural er- improvement over conventional imaging and helps with bet-
rors, such as off-course access, instrument fracture, or root ter assessment of the prognosis prior to the surgical treatment
perforation.118 The difficulty in locating calcified canals can (Fig. 2.26).
be further compounded by morphologic anomalies associ- The relationship of the teeth and the associated pathol-
ated with gender and ethnic origin.192 CBCT can be an ogy to important anatomic landmarks must be taken into
important adjunct to magnification and illumination in consideration in the treatment planning for endodontic
these cases. surgical procedures. These anatomic landmarks include,
but are not limited to, the maxillary sinus, the mandibular
PERFORATIONS canal, the mental foramen, the incisive canal, and the buc-
cal and lingual/palatine cortical plate. The close proximity
A perforation is defined as a “mechanical or pathologic com- of the maxillary posterior teeth to the sinus has been linked
munication between the root canal system and external to maxillary sinusitis of odontogenic origin; changes in the
tooth surface”9; it is usually associated with an iatrogenic maxillary sinus have ranged from thickening of the
event, accounting for about 10% of all nonhealed cases.102 Schneiderian membrane to actual accumulation of fluid in
Root perforations can be caused by a post preparation, the the sinuses.130,131,134 The relationship of the roots of the
search for a calcified canal, a strip perforation, or an at- posterior teeth to the sinus during presurgical treatment
tempt to retrieve a fractured instrument. They are often planning and the changes within the sinus can be best
difficult to localize with conventional imaging because no appreciated with the use of CBCT images.32,131,193
information about the buccolingual dimension can be ob- The relationship of the roots of the mandibular posterior
tained.232 Shemesh et al.194 compared the sensitivity and teeth and associated PA pathoses to the mandibular canal,
specificity of CBCT scans with two-angulation PA imaging the presence of an anterior loop, and the distance of the
using phosphor plates to assess the likelihood of detecting mandibular canal from the buccal and lingual cortical
root or strip perforations after root canal treatment with plates are pertinent pieces of information when surgical
laterally compacted gutta-percha and sealer. They found procedures in mandibular posterior teeth are planned.31
that the two methods showed similar specificity, but the The 3D nature of this relationship can be best assessed us-
CBCT image volumes showed higher sensitivity. Single- ing CBCT.113 A potential difference in the location of the
angulated PA radiographs showed 40% of the perforations, mandibular canal with respect to age and gender has been
and two-angled PAs showed 63%, suggesting that if PA ra- reported.116,197
diographs alone are used, two-angled images were superior. The determination of the thickness of the buccal cortical
There was no significant difference in the detection of root plates and anatomy of the root apex prior to endodontic
perforations between PA and CBCT radiography. The re- surgical procedures enables the clinician to preplan the os-
searchers noted that the results may have been affected by teotomy and the root end resection. The thickest buccal
the small size of the perforations and that the method of cortical plate was determined to be in the second molar
obturation did not favor extravasation of obturation mate- area as per a recent study.234
rial.194 CBCT images suffer from beam hardening artifact
resulting from root canal obturation and restorative materi- DENTOALVEOLAR TRAUMA
als (e.g., gutta-percha, posts, and perforation repair materi-
als), which creates challenges to the interpretation of root Dental trauma is common during the lifespan, with preva-
integrity. An approach advocated by Bueno et al.40 sug- lence in the primary dentition of approximately 30% and
gested that a map-reading strategy of viewing sequential in the permanent dentition of approximately 20%.12 Sys-
axial slices reduces the beam hardening effect. Improved tematic epidemiologic data at a large medical center sug-
CBCT software algorithms are expected to reduce artifact gest a prevalence of 48.2% for dental injuries in all facial
formation in the future. trauma, resulting in injuries to the dentition in 57.8% of
household and play accidents, 50.1% of sports accidents,
38.6% of work-related accidents, 35.8% of acts of vio-
Presurgical Treatment Planning lence, and 34.2% of traffic accidents, with 31% unspeci-
fied.78 The prevalence of traumatic dental injuries varies
Surgical endodontic treatment is often performed in cases according to the population studied, but these injuries
of endodontic nonhealing when nonsurgical retreatment is occur most commonly in children 7 to 10 years of age (also
not possible. In the past, conventional and digital 2D PA see Chapter 21).18 Dental traumatic injuries affect one
radiographs were the only means of assessing the apical fourth of all schoolchildren, with most injuries occurring
region. Unfortunately, the information available from these before the age of 19.81 Maxillary central incisors sustain
images may not adequately prepare the clinician to treat approximately 80% of all dental traumatic injuries, fol-
the pathosis surgically. For example, the clinician may be lowed by maxillary lateral incisors and mandibular inci-
unable to observe whether the lesion has perforated sors.16 The most common type of traumatic dental injuries
the buccal or palatal cortical plates, as in the example that in the primary dentition are luxation injuries, whereas

crown fractures are the predominant dental injury to the Intra-alveolar root fractures generally affect the perma-
permanent dentition.117 Determination of the extent of nent dentition of males and are relatively uncommon, ac-
injury to the dentinopulpal complex requires a methodical counting for 0.5% to 7% of dental impact injuries.19,54,84,154
approach that evaluates the teeth, periodontium, and as- Root-fractured teeth present diagnostic challenges, and the
sociated structures (Fig. 2.27) and may result in significant limitations of planar radiography have been well docu-
long-term complications.55 mented in the dental literature.50,58,115,159 A systematic
Trauma to the orofacial complex can result in the follow- retrospective study showed that maxillary central (68%)
ing injuries to the permanent dentition, based on the Inter- and lateral (27%) incisors were primarily affected, with
national Association of Dental Traumatology (IADT) guide- only limited occurrence in mandibular incisors (5%). This
lines: (1) infraction; (2) enamel fracture; (3) enamel-dentin retrospective study concluded that CBCT allowed for im-
fracture; (4) enamel-dentin-pulp fracture; (5) crown-root proved treatment planning and showed the true nature of
fracture without pulp exposure, (6) crown-root fracture with the injury compared with PA imaging alone.228 At least
pulp exposure; (7) root fracture; (8) alveolar fracture; (9) seven systematic laboratory studies and one systematic in
concussion; (10) subluxation; (11) extrusive luxation; vivo animal study reported significantly improved accuracy
(12) lateral luxation; (13) intrusive luxation; and (14) for the detection of root fractures when CBCT was com-
avulsion.13,58 (These guidelines can be reviewed at www. pared with PA radiography.95,96,101,135,155,225 In a systematic
[Link].) The IADT guidelines for assess- clinical study, Bornstein et al.33 examined 38 patients with
ment of permanent teeth at initial visit recommend expos- 44 permanent teeth that sustained intra-alveolar fractures.
ing several projections and angulations, with additional In the study sample reported, 68.2% of teeth had oblique
radiographs indicated when foreign objects become embed- fractures that extended to the cervical third of the root,
ded in soft tissue. However, the recommendations suggest contradicting the findings of previous studies conducted
that CBCT may be beneficial when used to assess patients with PA imaging alone. CBCT imaging offered improved vi-
after dental traumatic injuries, especially in cases of lateral sualization of the location and angulation of root fractures
luxation, root fracture, complications, and monitor healing. compared to PA and occlusal intraoral radiographs.33
The heterogeneity of dental traumatic injuries and difficulty Injuries that include fractures and comminution injures
in assessing affected teeth using intraoral radiography, espe- to the supporting structures or are difficult to visualize
cially when in the plane of PA radiographs, is evident from with intraoral imaging because of compression of overlying
the guideline recommendations.58 tissues, may be evident on CBCT scans. Several of these

Osteolysis Infraorbital canal Ethmoid air cell

Ostium Nasal fossa
Orbit
Mixed density appearance Middle conch
Sequestra
Inferior conch Incisive canal
Nasal septum
Thinning of Buccal cortex
lingual cortex

Mucositis

Localized sclerosis Inferior alveolar canal Maxillary sinus

Inferior mandibular Wide periodontal ligament space
A margin
Imaging stent Palate with torus Genial tubercle

B C

Extraction defect Dilated follicular space

Mental foramen
Mental foramen

D Inferior alveolar canal E

Fig. 2.26 A to W, Anatomic landmarks on CBCT images acquired using CS 9000, CS 9300, and iCAT units. (Carestream Dental, Atlanta, GA [CS 9000,
CS 9300]; and Imaging Sciences International, Hatfield, PA [iCAT].)
Continued

Superior genial canal

Inferior genial canal

Panoramic reformation

H
Extraction defect

Extraction defect

Crestal bone loss

Fracture

Mandibular tori

J I
Fig. 2.26, cont’d

Nasal fossa
Nasal fossa
Maxillary sinus with mucositis or fluid

Nasal septum Anterior nasal

spine
Buccal cortical plate
Hard palate
Lingual cortical plate

Hard palate
K N

Buccal cortex
Maxillary sinus with mucositis Incisive canal

Oro-antral
communication

L Extraction defect
Lingual cortex

Lateral wall of nasal fossa

O
Nasal septum

Inferior nasal conch

Incisive canal
Nasal fossa
Deviation of nasal septum Nasal septum
Maxillary sinus

Mucositis

Maxillary sinus with mucositis

Hard palate
M P
Fig. 2.26, cont’d
Continued

Nasal fossa Nasal septum

Incisive canal Nasal fossa

Radicular fracture
Radicular
following trauma
fracture
Voids

Hard palate Cervical

abfraction

Opening of incisive canal

Q
Maxillary sinus Nasal fossa Maxillary sinus

Widened apical periodontal U

Nasal septum ligament spaces
Nasal fossa

Buccal cortical plate

R
Dentinoenamel
Nasal fossa junction Palatal cortex
Orthodontic
hardware

Anterior nasal spine

Crestal bone loss

S Palate with torus

Inferior nasal conch Mental foramen

Lingual
Nasal septum
cortex
Mucositis

Focal osteoporotic Buccal cortex

W bone marrow defect
Right maxillary sinus
Palatal torus
Healing oro-antral
T communication
Fig. 2.26, cont’d

studies suggest that lower resolution scans using voxel sizes of traumatic injuries in which a root fracture or alveolar frac-
in excess of 0.3 mm may not improve radiographic assess- ture is suspected by providing undistorted multiplanar views
ments.96,225 A study by Wang et al.223 showed that the sen- of the dentition and supporting bone without the superimpo-
sitivity and specificity of PA radiography for root fractures sition of anatomic structures.47,127,187 CBCT image volumes
were 26.3% and 100%, respectively; the findings for CBCT provide superior sensitivity in detecting intra-alveolar root
were 89.5% and 97.5%, respectively. CBCT images of root- fractures compared with multiple PA radiographs; this allows
filled teeth with fractures showed lower sensitivity and for the detection of dental and alveolar displacements, includ-
unchanged specificity, whereas 2D images showed the same ing damage to other perioral structures, such as the maxil-
sensitivity and specificity.223 CBCT allows for the management lary sinus and nasal floor.105 The presence of root canal

A B C
Fig. 2.27 After a traumatic injury to the maxillary right and left central incisors, crown fractures were noted. The PA radiograph showed an extrusive
luxation injury in the maxillary left central incisor (A). The alveolar fracture (B, yellow arrow) and true extent of the displacement (C, yellow arrow) be-
came evident with CBCT. (Data acquired and reformatted at 0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

fillings and posts affected the specificity of the findings as a achievable” (ALARA) principle. CBCT scan volumes that
result of artifact generation.96,135 Outcome measurements of use the most appropriate detector size and shape, beam
a region of interest can be compared over time with greater projection geometry, and beam collimation should be
geometric accuracy using CBCT.94 selected to produce high-resolution images and reduce
Injury to the soft tissues, such as the lips, cheek and x-radiation exposure whenever possible.188 In all cases, it
tongue, by embedded debris and tooth fragments, usually should be recognized that children and young adults are
require additional radiographic images when relying on in- more susceptible to the effects of radiation than adults,
traoral radiography. CBCT scans will aid in wound manage- and CBCT studies should answer specific clinical questions
ment by locating the precise size and shape of the foreign that cannot be answered by lower dose PA and panoramic
body, possibly reducing the scope of surgical interventions.195 imaging techniques.97 In compliance with the Image
The healing of root fractures is influenced by many fac- Gently Alliance recommendations for pediatric imaging,
tors, most prominently the stage of root development, with always select x-rays when essential for diagnosis and treat-
immature roots showing better healing than mature roots.73 ment; use the fastest image receptor available, use CBCT
Other factors that influence healing are the extent of dislo- only when necessary, collimate beam to area of interest,
cation and repositioning, the type of splinting, the use of always use thyroid shield, and reduce exposure time and
antibiotics, and the location of the fracture on the root. The technique factors, such as mA.227 New technologies that
long-term survival of teeth with intra-alveolar root frac- allow for comparison of matched CBCT images in a serial
tures was evaluated in a systematic review by Andreasen et fashion at a reduced dose have been tested. This technol-
al.17 This study showed that the type of healing (e.g., hard ogy promises a dose reduction of 10 to 40 times by using
tissue fusion, PDL interposition with and without bone) and the initial scan as prior knowledge and adaptive prior im-
the location of the fracture on the root had the most influ- age constrained compressed sensing (APICCS) algorithms
ence on tooth loss. Yearly clinical and intraoral radiographic to greatly reduce the number of projections and x-ray tube
follow-up examinations are recommended by the IADT current levels required (Fig. 2.28).
for some injuries for up to 5 years posttrauma.58 Further
evidence-based comparisons of outcomes for traumatic INTERNAL AND EXTERNAL ROOT RESORPTION
dental injuries after treatment interventions were addressed
by the IADT with the development of a Core Outcome Set As described in Chapter 18, root resorption results in the
for children and adults. loss of dentin, cementum, or bone by the action of clastic
Limited FOV CBCT should be considered when place- cells.22 In the primary dentition, root resorption is caused by
ment of individual PA radiographs will adversely affect normal physiologic processes, except when resorption is
patient management or result in retakes; PA radiographs premature; in the permanent dentition, root resorption is
will produce a higher radiation dose for assessment of the caused by inflammatory processes.46,66,165 Root resorption
region of interest105; intra-alveolar fracture of the root or can be classified according to location as either internal, ap-
supporting structures is suspected and sufficient informa- pearing on the wall of the root canal, and external, affecting
tion cannot be obtained with conventional radiography; or the outer surface of the root. Both internal and external root
foreign bodies are present in the lip, cheek, or tongue.164 resorption have subtypes that show specific radiographic
The decision to use CBCT imaging for assessment of trau- characteristics.208
matic injuries should be based on the diagnostic yield ex- The successful management of root resorption in the adult
pected and in accordance with the “as low as reasonably dentition depends on clinical and radiographic examination

A B

C D Initial CBCT 7 year re-evaluation

E Initial CBCT 7 year re-evaluation F Initial CBCT 7 year re-evaluation

G Initial CBCT 7 year re-evaluation H

Fig. 2.28 A, Horizontal root fractures resulting from trauma were evident in this 22-year-old male patient, who was referred with a contemporaneous
film–based PA radiograph (B) for evaluation and possible treatment 9 months after trauma to his maxillary lateral and central incisors. Since the trauma,
the teeth had been stabilized with a ribbon-type splint on the palatal surface; they were of normal color and responded normally to all sensibility tests.
There was slight mobility of the traumatized teeth. C, The true nature of the root fractures are shown in the 3D segmented reformation and the cor-
rected cross-sectional views of the (D) maxillary right lateral and (E) central incisors, the (F) maxillary left central and (G) lateral incisors, and the 3D
surface-rendered reformation (H). Temporal reevaluation at 7 years showed minimal changes when compared to the initial presentation (left to right
in each group). Task-specific exposure parameters allowed each successive CBCT image volume to be exposed with lower mA, resulting in a 20% radia-
tion dose reduction. (Data acquired and reformatted at 0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA].)

leading to early detection and accurate diagnosis.166 Unfor- External root resorption (ERR) can be divided into four
tunately, teeth affected by root resorption have a poor prog- subtypes: external surface resorption, external inflammatory
nosis if the causative lesion is not treated.163 resorption, external replacement resorption, and external
2D radiographic projections suffer from inherent limita- cervical resorption (ECR). ERR may progress rapidly, and
tions that mask lesions: superimposition of 3D struc- early treatment is recommended.61
tures,27 geometric distortion,215 and misrepresentation.127 The recommended timing of radiographic examinations
Although parallax intraoral imaging techniques can be using CBCT has not been established with a strong evi-
helpful in localizing root resorption15 by observing lesion dence grade. Many ERR cases involve young patients in
shift on changing angulation, only CBCT assessments can whom the radiation dose is a critical factor and multiple
provide the true size and position of all resorptive defects in scans would be difficult to justify. To minimize radiation
the region of interest.46,163 Intraoral radiography is not dose to children the following guidelines have been sug-
reliable when lesions are small or located on the labial or gested: Select radiographs based on a patient’s individual
lingual/palatal surfaces.15 In ex vivo studies, CBCT showed needs, not as a routine; use the fastest image receptor pos-
improved accuracy in the detection of simulated internal sible; collimate the x-ray beam to expose only the area of
and external resorptive lesions of all sizes.107 Intraoral interest; use thyroid collars; reduce the exposure as appro-
imaging produced false-negative results in 51.9% of cases priate for the size of the child; use only when necessary,
studied and false-positive results in 15.3%.143 never as a screening tool.227
The use of CBCT in the evaluation of root resorption External surface resorption depends on the nature of the
eliminates superimposition and compression of 3D fea- stimulus and can vary from small, concave lesions to ex-
tures, is accurate in all multiplanar views, and can reliably tensive destruction of the root.14 Commonly caused by
represent the anatomy of three-dimensional structures. orthodontic treatment, proximity to other teeth, or cysts
Patel et al.163 compared the sensitivity and specificity of PA and tumors, radiographic imaging with CBCT allows for
imaging with CBCT scans using the receiver operating accurate multiplanar mapping of the lesion. These excava-
characteristic (ROC) analysis, a standard measure of diag- tions normally show small irregularities on the root sur-
nostic performance. PA imaging showed satisfactory ac- face with intact PDL and lamina dura. The appearance of
curacy (Az 0.78), whereas CBCT showed perfect results the ERR may help indicate the nature of the lesion, where
(Az 1.00).163 benign lesions tend to displace teeth and where more ag-
Internal root resorption (IRR) is usually idiopathic gressive lesions, such as malignant tumors, tend to cause
and can be subdivided into either internal inflammatory or extensive root resorption, showing either blunting of the
internal replacement resorption. IRR is a relatively rare root apex or spiked/knife-edge destruction (Fig. 2.29).165
occurrence that is usually detected on routine diagnostic External inflammatory resorption resulting from pulpal
radiographs.122,162 It is characterized by internal structural necrosis or traumatic injuries is radiographically character-
changes in the tooth that can appear in any location and ized by concave and occasionally patchy excavations of low
can exhibit varied features, such as smooth or irregular density that affect the root surface and the supporting
borders and radiodensity of uniform or mixed attenua- bone. Lesion borders are irregular, show loss of lamina
tion.99 IRR is usually asymptomatic, associated with pulpal dura, and are often associated with the apical region due to
necrosis coronal to the resorptive lesion and vital or par- the proximity of the apical terminus.
tially vital pulps where active.163 When viewed with intra- External replacement resorption is caused by damage to
oral radiographs, IRR can easily be confused with external the periodontium, which may result from dental trauma or
cervical resorption (ECR) owing to the similarity of the two orthodontic treatment.74 The teeth are immobile, have a
lesions.92 Parallax intraoral radiographs may aid identifica- distinctive tone on percussion, and show disappearance of
tion because the lesion will maintain its position relative to the normal periodontal membrane—features consistent
the root canal. However, assessment may be affected by ra- with a direct union with alveolar bone.
diographic superimposition and by teeth with complex External cervical resorption is a result of damage to the
anatomy. CBCT is helpful for diagnosing the location and cementum layer of the root by clastic activity. Further
exact size of IRR. In a study by Estrela et al.,66 48 PA radio- destruction of cementum and then dentin93 is dependent
graphs and CBCT scans were exposed on 40 individuals.66 on stimulating factors that include microorganisms from
IRR was detected in 68.8% of PA radiographs, whereas the periodontium.82 ECR is a complex and aggressive pro-
CBCT scans showed 100% of the lesions. Conventional cess and usually begins at the cervical region and may
radiographs were able to detect only lesions between 1 and result in a pink discoloration of the overlying enamel. Pa-
4 mm in 52.1% of the images, whereas CBCT was able to tients affected by ECR are usually asymptomatic because
show 95.8% of the lesions. This finding agreed with other the pericanal resorption-resistant/retarding sheet protects
studies that demonstrated the value of tomographic analy- the pulp until the later stages.209 Orthodontic treatment,
sis.46,125 In a study by Kim et al.,112 the extent and location trauma, parafunctional habits, and malocclusion account
of the IRR was accurately reproduced with the fabrication for most of these lesions, with a combination of factors re-
of a rapid prototyping tooth model. Although relatively sulting in increased occurance.167 Intraoral radiography
few systematic studies on artificially induced IRR have been shows significant variability, with areas of low density
reported because of the difficulty in creating such defects, affecting the dentin extending coronally and/or apically
Kamburoglu and Kursun106 concluded that high-resolution with sometimes greater destruction distant from the origin
CBCT imaging performed better than low-resolution CBCT on the buccal or lingual/palatal aspect of the root, con-
imaging in detecting simulated small internal resorptive founding 2D radiographic assessment. The radiographic
lesions. appearance of these lesions is often mixed owing to the level

PA radiography at diagnosing ECR according to the Hei-

thersay classification.216
ERR is difficult to detect if the lesion is confined to the
buccal, palatal, or lingual surfaces of the root.30,83 Liedke
et al.125 conducted systematic diagnostic performance tests
and showed similar sensitivity and specificity among the
different voxel sizes studied (0.4, 0.3, and 0.2 mm); how-
ever, the likelihood ratio showed better probability of cor-
rect identification of ERR with either 0.3 or 0.2 mm scans.
These researchers suggested the use of a 0.3 mm voxel size
protocol rather than a 0.2 mm one, to reduce scanning
time and the resulting dose.125 Although voxel size is an
important consideration, the SNR of different detectors,
A B the radiation dose, viewing conditions, and the processing
algorithms also affect detection probability.
Even though many in vitro studies have been performed
on the ability of CBCT to detect root resorption, additional
evaluations that use in vivo methodology will add to the
cumulative knowledge.

Endodontic Treatment Outcomes

Assessment
The reduction of inflammation and healing through regener-
ation or repair are the ideal outcomes for endodontic treat-
ment.148 However, endodontic treatment outcome predictors
using PA radiographs and CBCT imaging have been shown to
vary and are influenced by factors such as patient inclusion
and exclusion criteria.124 Historically, PA radiographs and
C D physical examinations were used to determine the success of
endodontic treatment, and the absence of posttreatment peri-
Fig. 2.29 A, External cervical resorption was evaluated in this patient radicular radiolucencies and symptoms was considered by
after PA radiographic image, and (B) visual examination showed
pathognomonic signs of this lesion (yellow arrow). A CBCT image was many to be the criterion for success. However, these planar
exposed to determine the true extent of resorption and restorability. imaging-based studies have resulted in an overestimation of
C, The lesion showed a perforative defect at the CEJ on the facial successful outcomes, compared to CBCT assessments,230 be-
(yellow arrow) and (D) palatal aspects (yellow arrow). D, The presence cause AP confined within the cancellous bone or lesions cov-
of an intact layer of mineralized dentin, the “pericanalar resorption-
resistant sheet” (blue arrow), is a hallmark of this condition. (Data ac-
ered by a thick cortex may be undetectable with conventional
quired and reformatted at 0.076 mm voxel size using a CS 9000 3D unit radiographic assessments.26 Additional discrepancies between
[Carestream Dental, Atlanta, GA].) PA radiography and CBCT have resulted from geometric dis-
tortion, limiting comparisons of temporal evaluations, even
with careful attention to paralleling technique factors.133
of fibro-osseous and granulomatous tissue present. Exter- A clinical study comparing the sensitivity, specificity,
nal cervical resorption is located on the external surface of predictive values, and accuracy of PA and panoramic radi-
the root, showing an intact root canal wall that can be ography and CBCT imaging in 888 consecutive patients
traced through the lesion, whereas IRR is continuous with showed that the prevalence of AP in root-treated teeth
the canal wall. was 17.6%, 35.3%, and 63.3%, respectively. Conventional
External cervical resorption is always associated with radiography showed increased accuracy when the larger
bony resorption, making comparability of laboratory stud- lesions were assessed.67
ies problematic because the lesions lack the changes in the Using histologic examination as the gold standard, a sys-
periodontal membrane and associated bony changes that tematic review and meta-analysis of the literature by Dutra
would improve visualization. The early stages of ERR are et al.121 compared different radiographic modalities in the
difficult to view with conventional radiography, and lesions binary assessment of AP versus no lesion in humans—a
less than 0.6 mm in diameter and 0.3 mm in depth could very important measure in outcome studies. Significantly,
not be detected. Medium-sized lesions were visible in 6 of only nine studies were ultimately selected for qualitative syn-
13 cases, with improved visualization for proximal lesions thesis and only six for meta-analysis. All included studies
without regard to the root third being examined.15 Patel were limited by using only artificially induced apical lesions,
et al. showed that the accuracy of parallax and single paral- possible bias, variation in bone lesion sizes, poor or no inter-
lel PA radiographs were similar, and that more teeth were and intraobserver agreement, and except for one study, did
considered unrestorable when assessed with CBCT (78.7%) not evaluate the maxilla, where more tissue compression
than with PA imaging (49.3%).158 This study further high- occurred. This study showed the accuracy values of 0.72 for
lights the benefits of using CBCT to assess ECR.158 Vaz de digital PA radiographs, 0.73 for film-based PA radiographs,
Souza et al. showed that CBCT was significantly better than and 0.96 for CBCT.121

Outcome predictors identified with PA radiographs and negative predictive value (NPV) of PA radiography at
CBCT scans may be different depending on the research 0.25, showing that when the PA tissues had a normal ap-
performed. Liang et al.124 retrospectively evaluated 115 pearance, 75% actually had AP. CBCT scans resulted in an
endodontically treated teeth with vital pulps 2 years after NPV almost two times higher than that for PA radiography;
treatment. The authors noted that the recall rate of 36% however, CBCT scans were not able to detect some AP that
was comparable to that in other studies, but the result may was confined to the apical foramen or had little volumetric
have been affected because patients with symptomatic or bone loss. The positive predictive value was the same for
already extracted teeth may not have responded. This lost- PA radiography and CBCT scans compared with histologic
to-follow-up cohort significantly reduced the level of evi- examination, but true positive and true negative diagnosis
dence.75 PA radiography identified PA lesions in only 12.6% of AP using CBCT scans occurred in 92% of cases.
of teeth compared to CBCT images, which identified 25.9% Continuing development of sophisticated postprocessing
of teeth with PA lesions. In multivariate logistic regression software now allows for modeling of AP and anatomic struc-
analysis, the extent of root fillings and density were out- tures in 3D. Using either manual or semiautomatic segmen-
come predictors when using PA imaging, whereas density tation, the resulting virtual models allow for alignment and
of root fillings and quality of the coronal restoration were analysis of temporal changes, with some limitations. Bony
outcome predictors when using CBCT scans. changes can be depicted in quantitative and qualitative
The predictive value and diagnostic accuracy of radio- datasets, showing bone density changes such as repair or
logic assessments are critical to the practice of dentistry, osteolysis. One of these programs, ITK-SNAP, an open-source
and the diagnostic value of radiographs depends on the software originally developed for MRI assessments, allows for
radiograph’s ability to show the histology of AP. De Paula- construction of virtual 3D models from DICOM datasets,
Silva et al.53 evaluated the periapex of 83 root-treated and showing volumetric measurements in voxels and cubic mil-
untreated dogs’ teeth using PA radiography, CBCT scans, limeters. Additional tools allow for calculation of the mean
and histopathologic analysis. PA radiography detected intensity of the PA rarifying lesion(s) of interest. The result-
AP in 71% of roots; CBCT scans detected AP in 84%; and ing scan data can then be exported in STerioLithography
histologic analysis detected AP in 93%. These findings, format (STL) and shown in 3DMeshMetric software
corroborated by other studies,38,87,178 emphasized the low (Figs. 2.30 and 2.31).

A B

C D
Fig. 2.30 The problem of superimposition of unrelated structures onto the features of interest is reduced when tomographic slices are used instead of
images in which an entire volume of data is compressed into a planar image. A, This PA radiographic image of the maxillary left second molar shows
no radiographic indicators of pathosis. A contemporaneously exposed CBCT image (B, corrected sagittal view) shows a 4.3 3 1.9 mm, well-defined
unilocular, noncorticated area of low attenuation centered over the apex of the mesiobuccal root, consistent with a periradicular periodontitis (yellow
arrow). There is a moderate mucositis in the region of the maxillary sinus adjacent to this tooth (blue arrow). Experimental semiautomated segmenta-
tion of this image using active contour methods (ITK-SNAP) allowed for measurement of the true volume of the lesion (C) and for future temporal
comparisons based on volumetric measurements (D). This lesion measured 85,112 voxels and 38.1044 cubic mm. (Data acquired and reformatted at
0.076 mm voxel size using a CS 9000 3D unit [Carestream Dental, Atlanta, GA]; volumetric segmentation and measurement using ITK-SNAP [Radiology Depart-
ment, School of Medicine, University of Pennsylvania].)

A B

C D
Label Id Label name Number of Voxels Volume (mm3) Image mean Image Stdev
0 Clear Label 13716676 6146.24 565.658 1074.02
1 Vol1 15704 7.03673 –45.4508 58.9991
2 Vol2 19059 8.54006 –70.2623 77.7926
E

1.68 1.68

1.26 1.26

0.839 0.839

Buccal Palatal 0.420 0.420

0.000 0.000

Mesial Distal Value of point : 0.281644 Mesial Value of point : 1.30288 Distal
F G
Fig. 2.31 Radiographic interval change is shown by comparing two volumetric datasets exposed at different times. A, Initial CBCT corrected sagittal
reformation of maxillary right second molar, distobuccal root and (B) corrected sagittal reformation of same root at 13-month checkup. C and D, ITK-
SNAP segmented sagittal reformation of same root. Alignment and overlap of the 3D models: tooth-blue, initial lesion is red, lesion at 13-month check-
up is yellow, respectively. E, Voxel counting, volumetric measurement (mm) and mean intensity of the periapical lesion. F, Models were exported to
the .stl format and then viewed with MeshLab software. G, 3D Mesh Metric Qualitative (color-coded map) and quantitative (point value) assessments
of the lesions before (translucent), and after (colored). The color map shows changes with green color in the mesial region (0.28 mm) and changes with
dark red color in the distal region (1.30 mm). (Courtesy Dr. Ane Poly.)

Risks and benefits for patients who are medically com- systems provide improved accuracy when compared with
plex and subject to possible increased morbidity from AP, freehand methods.29
such as patients with an altered immune system (i.e., che- Pathoses of the jaws, such as retained root tips, inflam-
motherapy or anti-HIV protocols or prosthetic joints and/ matory lesions, cysts, and tumors, in addition to extraoral
or infective endocarditis), should be considered in the deci- structures, such as the sinuses and temporomandibular
sion about whether to expose a CBCT scan. The American joints (TMJs), must also be assessed.97 CBCT imaging
Academy of Periodontology has published a position paper should be considered to evaluate implant sites in the
stating that periodontal disease may contribute to adverse region of teeth with a high likelihood of periradicular
systemic health conditions.186 The scientific basis for the pathosis.239
relationship of AP and adverse systemic health conditions
has not been established43; however, new associations 3D-GUIDED ENDODONTICS
between AP and systemic health should be predicated on
research that uses CBCT in the detection of endodontic 3D-guided surgical and nonsurgical endodontic treatment
disease.49 is an emerging application using guides manufactured with
The determination of successful outcomes is nuanced the aid of CBCT images and intraoral scanning of the area
and complex. New AAE-sponsored initiatives to study out- of interest. Although studies with high level of evidence is
comes is underway and will ultimately result in an agreed lacking in this area, several in vitro studies and case reports
standardized set of criteria, called a “core outcomes set,” have been published.5,48,118,132
facilitating data synthesis and possibly resulting in more The technology is currently being utilized in endodontic
transparent and complete reporting. treatment of teeth with calcified canals and teeth that have
anatomical variations of the root canal system. A template
is created by superimposition of CBCT images on intraoral
Dental Implant Case Planning scanned images with sleeves placed in the images for creat-
ing a 3D printed guide with a directed sleeve. Most often
Successful endosseous implant site assessment requires the implant treatment planning software is used for the creation
development of a prosthetically driven approach,2 with of the guide (Fig. 2.32).48,118,132 Recent study evaluating
special emphasis on the evaluation of bone volume, the os- access on calcified teeth showed a higher detection of canal
seous topography, and the location of anatomic structures (91.7% vs. 41.7%) using guided approach. There was
in relation to the positioning of the implant. The AAOMR significantly lower amount of tooth substance loss using the
has published advisory recommendations suggesting all guided access (49.9 mm vs. 9.8 mm).48
radiographic studies should interface with the dental and Endodontic microsurgery aims to create conservative os-
medical histories, clinical examinations, and treatment teotomy utilizing magnification and microsurgical instru-
planning. Panoramic radiography, which may be supple- ments. Various studies have shown improved prognosis with
mented by PA radiography, should be used for initial imag- the microsurgical procedures when compared to traditional
ing assessments. Cross-sectional imaging, including CBCT, endodontic surgery.210 Surgical treatment planning with
should not be used as an initial imaging examination. CBCT images have aided clinicians in identifying anatomical
The AAOMR affirms the need for cross-sectional imaging in structures in the surgical area and increasing precision of
the preoperative diagnostic phase, recommending CBCT the procedure.119 Surgical endodontics with 3D-guided tem-
because it provides the highest diagnostic yield at an ac- plates has further helped in making microsurgical proce-
ceptable radiation dose risk. CBCT should be used at the dures more precise.3,5,71 A recent study comparing “free-
smallest FOV necessary, with optimized technique factors, hand” CBCT-aided surgery to surgery using template guides
to minimize radiation dose in accordance with the ALARA showed a deviation of 1.743 mm when using guides from
principle.213 the target location identified on preoperative CBCT. Free-
CBCT allows for precise planning and delivery of im- hand surgery showed a deviation of 2.638 mm.3 Use of
plants that can reproduce the anatomy with submillimet- prefabricated grids placed while acquiring CBCT images
ric accuracy, leading to improved outcomes.201 The use of were used as guides for creating osteotomy during endodon-
CBCT to assess linear measurements, proximity to vital tic surgery in a recent study. Deviation from the target point
anatomic structures, mapping of the alveolar ridge topog- was significantly lower when compared to nonguided drill-
raphy, and fabrication of surgical guides is supported by ing (Fig. 2.33).71
the dental literature. The use of CBCT to gauge bone den-
sity, provide intraoperative surgical navigation, and assess
implant integration is generally considered an area that Image Perception and Viewing
requires further research.25 Environment
Virtual implant planning using CBCT data allows clini-
cians to visualize the result before the commencement of Medical image perception is an important area of knowl-
treatment, facilitating the virtual investigation of multiple edge, and ongoing research relies on an understanding of
treatment scenarios until the best plan is attained. The perceptual issues, such as psychological factors, dwell time,
evaluation of bone dimensions, bone quality, the long axis visual search physiology, search tactics, appreciation for
of the alveolar bone, internal anatomy, and jaw boundaries; the reading environment, and fatigue factors, to increase
the detection of pathologic features; and the transfer of ra- search satisfaction. Understanding these issues may im-
diographic information are the main imaging goals. Use of prove the ability to interpret and report on dental radio-
static, CT-generated guide stents and dynamic navigation graphic findings.185

A B

C D

Fig. 2.32 Guided access flow chart. A, 2D rendering from the CBCT of a
block of 2 molars. B, Volumetric rendering of the teeth. C, Lateral view of
the teeth with virtual files in position. D, Printed guide. E, Representative
occlusal view of an accessed tooth. (Courtesy Dr. Zachary Evans and Dr.
E Bryce Szczepanik, MUSC, Charleston, SC.)

The increasing use of digital radiography in the dental The Future of Cone-Beam
environment has led to a sea change in workflow and the Computed Tomography
necessity for new ways to view and document radiographic
images. Simple to accomplish, but important to improve, The first decade of the 21st century saw the development of
are the viewing conditions for softcopy interpretation, in- a wide range of CBCT applications, especially in dentistry.
cluding moderately reduced ambient lighting, ranging from Lower radiation dose, higher spatial resolution, smaller
25 to 40 lux.36 FOV, and relatively lower cost may contribute to CBCT

A B C
Fig. 2.33 Guided endodontic surgery. A, 3D printed guide. B, Guide placed in position prior to endodontic surgery. C, Surgical access with printed
guide in position. (Courtesy Dr. Ackerman and Dr. Jalali, Texas A&M College of Dentistry, Dallas, TX.)

becoming the standard of care in 3D dentomaxillofacial Magnetic Resonance Imaging

imaging in selected cases. CBCT systems are increasingly
being used in medical applications, such as operating MRI has been explored as a potentially useful imaging mo-
rooms, emergency departments, intensive care units, and dality in dentistry, and in particular endodontics. Advan-
private otolaryngology offices. Operating room–based C- tages include nonexposure to ionizing radiation; capability
arm systems have been in use for a number of years, with to acquire images in any desired plane without having to
applications in interventional angiography, cancer surgery, reformat data; capability to image edema, effusion, and in-
vascular surgery, orthopedic surgery, neurosurgery, and flammation in the adjacent bone; spread of infection; better
radiotherapy.69 Applications in otolaryngology and mam- soft-tissue delineation; and assessment of root structure
mography are common, and imaging of extremities in and variations in canal morphology and/or number. Disad-
weight-bearing scenarios is under development. Many of vantages include high cost of a scanner, longer acquisition
these applications rely on systems that use task-specific times, interpretation challenges due to differences in ap-
protocols that benefit from CBCT’s 2D FPDs, which allow pearance of hard and soft tissue as compared to CBCT or
for a single rotation of the source to generate a study of the conventional radiographs, potential for motion artifacts,
region of interest, as opposed to complex MDCTs that use limited resolution, lack of easy access, choice of appropri-
redundant imaging via multiple slice acquisitions to generate protocol based on scanner parameters, and generation
ate a 3D volume.196 of artifacts unlike those seen on x-ray–based images. All of
The introduction of new, high-performance, flat-panel these challenges need to be addressed in order for the imag-
detectors and software algorithms centering on improving ing modality to be widely accepted and used in endodontics.
the noise-power spectrum and noise-equivalent quanta will Various pulse sequences have been developed for optimizing
continue to increase the utility of CBCT systems in the fu- image quality for endodontic diagnostic purposes, but a
ture. Areas of research include (1) image perception and magnetic field strength that is sufficiently high to improve
image quality assessment, to better understand how physi- resolution and further fine-tuning of task-specific regional
cians and dentists analyze radiographic images and thereby receiver coils are required.20,57
improve diagnostic decision making202; (2) iterative recon-
struction that uses sophisticated algorithms to reduce arti-
facts; (3) known-component reconstructions that use a Conclusions
model-based 3D image reconstruction and iterative soft-
ware to reduce image artifacts in the presence of metallic Digital radiography has several advantages and has become
devices such as screws and implants; (4) image registration an indispensable diagnostic tool for many dentists in daily
to align tissues for image-guided surgery and outcomes as- practice. Once the digital image appears on the monitor, the
sessment;141 (5) image-guided procedures that provide in- dental x-ray software allows image enhancement, which
stantaneous surgical navigation; (6) segmentation to allow should be used with caution and be based on the diagnostic
discrimination between normal and diseased tissues and task. Inappropriate use of enhancement has been shown to
permit volumetric measurements (see Figs. 2.30 and 2.31); adversely affect diagnosis.142 If digital radiographs are ex-
and (7) use of metallic artifact reduction algorithms that ported using various software packages created for graphic
help partly remove distracting signals and artifacts from a design and image manipulation, digital information can be
CBCT study. Note, however, that there is potential for loss of altered, added, or removed. The DICOM standard has been
diagnostic information as well, especially in situations accepted as the universal standard for image transmission
where high spatial resolution is required, such as detection and archiving, so that each image can be transmitted and
of vertical root fractures in roots with posts. stored without the use of proprietary software that would

seriously limit its distribution. DICOM ensures that all im- unrecognized by those who have not received specific train-
ages are readable in any viewing software without loss of ing in the interpretation of regional anatomy. Image pro-
fidelity or diagnostic information. Image enhancement fea- cessing can greatly alter signal characteristics, thus render-
tures of digital radiography allow mishandling of images, ing the task fairly challenging. Besides, if other pathoses are
leading to potential abuse. Published studies illustrate the discovered, additional imaging may be necessary, including
potential for fraudulent use of digital radiography.42 MRI, nuclear medicine studies, or even MDCT, for the eval-
There is a dearth of studies related to the diagnostic per- uation of soft tissues, with and without the use of contrast.
formance of the different sensor types currently available The advent of 3D imaging has provided the endodontist
on the market. Slight to moderate differences in spatial with tools that were not available until now, facilitating in-
resolution capabilities exist. With rapid advancement in teractive image manipulation and enhancement and thus
sensor technology and frequent software upgrades, selec- significantly increasing the amount of information that
tion of one system over another for a specific diagnostic can be gleaned from a volume. Lack of distortion, magnifi-
task may appear challenging. A review of the most com- cation, artifacts associated with conventional radiography,
monly used solid-state sensors notes that most systems and the relative low radiation dose compared to medical-
perform comparably with intraoral film and also allow for grade CT will result in more clinicians adopting such tech-
postprocessing of images, which is not possible with film- nology to enable accurate diagnoses and treatment plan-
based images. Other factors that assume significance in this ning, in addition to long-term follow-up and the evaluation
context are the availability of technical and customer sup- of healing. Judicious use of CBCT and all other imaging
port, frequency of both hardware and software upgrades, modalities using ionizing radiation is advocated. The AAE/
dimensions of the sensor and its active area, number of AAOMR position paper provides recommendations for the
sensors needed in a practice (and thus cost issues), the de- use of CBCT in endodontics1 and is presented at the end of
tector quantum efficiency (DQE), and conformance to the this chapter.
DICOM standard for seamless integration with other sys- When the clinician works with different vendor products,
tems. CCD/CMOS sensors appear to offer the best contrast it is important to have a quality assurance program in
and spatial resolution, in addition to facilitating instanta- place. This is not being done currently. Additionally, ac-
neous image capture, and therefore are recommended for creditation of stand-alone imaging laboratories is now a
endodontic applications. Careful and appropriate image requirement for reimbursement of medical and dental diag-
processing further helps tease out the signal of interest. In nostic procedures from government agencies and some
an enterprise-wide setting or in larger private practices that major third-party insurance providers. Several states are
have multiple specialty areas, PSP-based sensors may be considering enforcing this requirement to prevent abuse
more cost effective for large volume imaging (e.g., full of CBCT.
mouth series of radiographs). However, at least one or two Likewise, definitive referral criteria are lacking. Indica-
CCD/CMOS-based systems should be available for faster im- tions, contraindications, and choice of alternate imaging
age acquisition, such as for endodontic purposes and intra- modalities need to be considered before CBCT is used.
operative procedures. There is a learning curve to this technology, and appropri-
It is recommended that the literature be constantly re- ate positioning, choice of exposure parameters (and thus
viewed for updates on digital radiography and advanced the effective dose), reconstruction schemes, choice of post-
imaging modalities for specific endodontic applications be- processing algorithms based on diagnostic task, voxel sizes,
cause hardware and software upgrades continue to make and cost must be considered. The literature contains few
rapid progress. Previous studies have shown that most digi- studies to help us formulate definitive guidelines for the use
tal images performed comparably to conventional intraoral of CBCT in dentistry.
film for a variety of diagnostic tasks. Most of these studies It is equally important to record the doses associated with
were done with earlier generation sensors. The advances in each study. Accreditation criteria have been developed by
sensor technology have resulted in greatly enhanced image the Intersocietal Accreditation Commission for CT in den-
quality, and this trend is expected to continue. Also of inter- tistry that are useful for ensuring the safe use of these units.
est in the future will be the use of task-based, appropriate The lowest possible dose must be imparted to the patient as
image processing parameters that result in a reduced radia- part of a radiologic examination to minimize stochastic ef-
tion dose and significant enhancement of the diagnostic fects that have no known threshold for expression. No dose
information. Automation of this process will result in faster can be considered a “safe dose.” The benefits of any radio-
and more consistent image processing based on the diag- graphic study must outweigh the risks. All studies must be
nostic task. Such procedures are routinely carried out in interpreted fully because signals from adjacent areas may
medical radiology. appear in the volume of interest, including small FOV stud-
Three-dimensional imaging will continue to be used ex- ies. Retakes can be avoided by adhering to protocol selection
tensively as sensor characteristics improve and more user- based on the task at hand. The ALARA principle must be
friendly software is introduced. As bit-depth and spatial followed, regardless of the dose values reported by the ven-
resolution of images increase, CBCT will continue to be ex- dor, to optimize the dose for the specific examination. Use of
plored for more applications in endodontics. Image inter- thyroid collars and lead aprons is recommended in the
pretation also is important. Occult pathology and inciden- NCRP guidelines, as long as they do not interfere with im-
tal findings in adjacent regions can be easily missed or go age acquisition.

JOINT POSITION STATEMENT OF THE AMERICAN ASSOCIATION

OF ENDODONTISTS AND THE AMERICAN ACADEMY OF ORAL
AND MAXILLOFACIAL RADIOLOGY ON THE USE OF CONE BEAM
COMPUTED TOMOGRAPHY IN ENDODONTICS: 2015/2016
UPDATE

This statement was prepared by the Special Committee to Volume Size(s)/Field of View
Revise the Joint AAE/AAOMR Position Statement on Use of
CBCT in Endodontics and approved by the AAE Board of There are numerous CBCT equipment manufacturers, and
Directors and AAOMR Executive Council in 2016. several models are available. In general, CBCT is categorized
into large, medium, and limited-volume units based on the
size of their “field of view” (FOV). The size of the FOV de-
Introduction scribes the scan volume of CBCT machines. That volume
determines the extent of anatomy included. It is dependent
This updated joint position statement of the American Asso- on the detector size and shape, beam projection geometry,
ciation of Endodontists (AAE) and the American Academy of and the ability to collimate the beam. To the extent practi-
Oral and Maxillofacial Radiology (AAOMR) is intended to pro- cal, FOV should only slightly exceed the dimensions of the
vide scientifically based guidance to clinicians regarding the anatomy of interest.
use of cone-beam computed tomography (CBCT) in endodon- Generally, the smaller the FOV, the lower the dose associ-
tic treatment and reflects new developments since the 2010 ated with the study. Beam collimation limits the radiation
statement.1 The guidance in this statement is not intended to exposure to the region of interest and helps ensure that an
substitute for a clinician’s independent judgment in light of optimal FOV can be selected based on disease presentation.
the conditions and needs of a specific patient. Smaller scan volumes generally produce higher resolution
Endodontic disease adversely affects quality of life and images. Because endodontics relies on detecting small
can produce significant morbidity in afflicted patients. Radi- alterations such as disruptions in the periodontal ligament
ography is essential for the successful diagnosis of odonto- space, optimal resolution should be sought.5
genic and nonodontogenic pathoses, treatment of the root The principal limitations of large FOV CBCT imaging are
canal systems of a compromised tooth, biomechanical in- the size of the field irradiated and the reduced resolution
strumentation, evaluation of final canal obturation, and compared to intraoral radiographs and limited volume
assessment of healing. CBCT units with inherent small voxel sizes.4 The smaller the
Until recently, radiographic assessments in endodontic voxel size, the higher is the spatial resolution. Moreover, the
treatment were limited to intraoral and panoramic radi- overall scatter generated is reduced due to the limited size of
ography. These radiographic technologies provide two- the FOV. Optimization of the exposure protocols keeps doses
dimensional representations of three-dimensional anatomic to a minimum without compromising image quality. If a
structures. If any element of the geometric configuration is low-dose protocol can be used for a diagnostic task that
compromised, the image may demonstrate errors.2 In more requires lower resolution, it should be employed, so long as
complex cases, radiographic projections with different beam strong indications to the contrary are absent.
angulations can allow parallax localization. However, com- In endodontics, the area of interest is limited and deter-
plex anatomy and surrounding structures can render inter- mined prior to imaging. For most endodontic applications,
pretation of planar images difficult. limited FOV CBCT is preferred to medium or large FOV CBCT
The advent of CBCT has made it possible to visualize the because there is less radiation dose to the patient, higher
dentition, the maxillofacial skeleton, and the relationship spatial resolution, and shorter volumes to be interpreted.
of anatomic structures in three dimensions.3 CBCT, as with
any technology, has known limitations, including a possible
higher radiation dose to the patient. Other limitations in- Dose Considerations
clude the potential for artifact generation, high levels of
scatter and noise, and variations in dose distribution within Selection of the most appropriate imaging protocol for the
a volume of interest.4 diagnostic task must be consistent with the “as low as rea-
CBCT should be used only when the patient’s history and a sonably achievable” (ALARA) principles that every effort
clinical examination demonstrate that the benefits to the pa- should be made to reduce the effective radiation dose to the
tient outweigh the potential risks. CBCT should not be used patient “as low as reasonably achievable.” Because radia-
routinely for endodontic diagnosis nor for screening purposes tion dose for a CBCT study is higher than that for an intra-
in the absence of clinical signs and symptoms. Clinicians oral radiograph, clinicians must consider overall radiation
should use CBCT only when the need for imaging cannot be dose over time. For example, will acquiring a CBCT study
met by lower dose two-dimensional (2D) radiography. now eliminate the need for additional imaging procedures

in the future? It is recommended to use the smallest possible treatment outcome. Success, when measured by radio-
FOV, the smallest voxel size, the lowest mA setting (depend- graphic criteria, is higher when teeth are endodontically
ing on the patient’s size), and the shortest exposure time in treated before radiographic signs of periapical disease
conjunction with a pulsed exposure-mode of acquisition. are detected.8
If extension of pathoses beyond the area surrounding n Previous findings have been validated in clinical studies
the tooth apices or a multifocal lesion with possible sys- in which primary endodontic disease detected with in-
temic etiology is suspected, and/or a nonendodontic cause traoral radiographs and CBCT was 20% and 48%, re-
for devitalization of the tooth is established clinically, ap- spectively. Several clinical studies had similar findings,
propriate larger field of view protocols may be employed on although with slightly different percentages.9,10 Ex vivo
a case-by-case basis. experiments in which simulated periapical lesions were
There is a special concern with overexposure of children created yielded similar results.11,12 Results of in vivo ani-
(up to and including 18-year-olds) to radiation, especially mal studies, using histologic assessments as the gold
with the increased use of computed tomography scans in standard, also showed similar results as those observed
medicine. The AAE and the AAOMR support the Image in human clinical and ex vivo studies.13
Gently Campaign led by the Alliance for Radiation Safety in n Persistent intraoral pain following root canal therapy
Pediatric Imaging. The goal of the campaign is “to change often presents a diagnostic challenge. An example is per-
practice; to raise awareness of the opportunities to lower sistent dentoalveolar pain also known as atypical odon-
radiation dose in the imaging of children.” Information talgia.14 The diagnostic yield of conventional intraoral
on use of CT is available at [Link] radiographs and CBCT scans was evaluated in the dif-
Procedures/[Link]. ferentiation between patients presenting with suspected
atypical odontalgia versus symptomatic apical periodon-
titis, without radiographic evidence of periapical bone
Interpretation destruction.15 CBCT imaging detected 17% more teeth
with periapical bone loss than conventional radiography.
If a clinician has a question regarding image interpretation, it
should be referred to an oral and maxillofacial radiologist.6 INITIAL TREATMENT
Preoperative
Recommendations Recommendation 3: Limited FOV CBCT should be
considered the imaging modality of choice for the
The following recommendations are for limited FOV CBCT initial treatment of teeth with the potential for ex-
scans. tra canals and suspected complex morphology, such
as mandibular anterior teeth, and maxillary and
mandibular premolars and molars, and dental
DIAGNOSIS
anomalies.
Endodontic diagnosis is dependent upon thorough evalua-
tion of the patient’s chief complaint, history, and clinical Intraoperative
and radiographic examination. Preoperative radiographs Recommendation 4: If a preoperative CBCT has not
are an essential part of the diagnostic phase of endodontic been taken, limited FOV CBCT should be considered as
therapy. Accurate diagnostic imaging supports the clinical the imaging modality of choice for intra-appointment
diagnosis. identification and localization of calcified canals.
Recommendation 1: Intraoral radiographs should
be considered the imaging modality of choice in the Postoperative
evaluation of the endodontic patient. Recommendation 5: Intraoral radiographs should be
Recommendation 2: Limited FOV CBCT should be considered the imaging modality of choice for imme-
considered the imaging modality of choice for diag- diate postoperative imaging.
nosis in patients who present with contradictory or
nonspecific clinical signs and symptoms associated Rationale
with untreated or previously endodontically treated n Anatomical variations exist among different types of

teeth. teeth. The success of nonsurgical root canal therapy

depends on the identification of canals, the cleaning,
Rationale shaping and obturation of root canal systems as well as
n In some cases, the clinical and planar radiographic the quality of the final restoration.
examinations are inconclusive. Inability to confidently n 2D imaging does not consistently reveal the actual num-

determine the etiology of endodontic pathosis may be ber of roots and canals. In studies, data acquired by
attributed to limitations in both clinical vitality testing CBCT showed a very strong correlation between section-
and intraoral radiographs to detect odontogenic patho- ing and histologic examination.16,17
ses. CBCT imaging has the ability to detect periapical n In a 2013 study, CBCT showed higher mean values of

pathosis before it is apparent on 2D radiographs.7 specificity and sensitivity when compared to intraoral
n Preoperative factors such as the presence and true size of radiographic assessments in the detection of the MB2
a periapical lesion play an important role in endodontic canal.18

places the patient at risk and may result in unnecessary

NONSURGICAL RETREATMENT
treatment. Treatment planning decisions using CBCT
Recommendation 6: Limited FOV CBCT should be versus intraoral radiographs were compared to the gold
considered the imaging modality of choice if clinical standard diagnosis.23 An accurate diagnosis was reached
examination and 2D intraoral radiography are in- in 36% to 40% of the cases with intraoral radiographs
conclusive in the detection of vertical root fracture compared to 76% to 83% with CBCT. A high level of
(VRF). misdiagnosis was noted in invasive cervical resorption
and vertical root fracture. In this study, the examiners
Rationale altered their treatment plan after reviewing the CBCT in
n In nonsurgical retreatment, the presence of a vertical 56% to 62.2% of the cases, thus indicating the signifi-
root fracture significantly decreases prognosis. In the cant influence of CBCT.
majority of cases, the indication of a vertical root frac-
ture is more often due to the specific pattern of bone loss SURGICAL RETREATMENT
and periodontal ligament space enlargement than to di-
rect visualization of the fracture. CBCT may be recom- Recommendation 9: Limited FOV CBCT should be
mended for the diagnosis of vertical root fracture in un- considered as the imaging modality of choice for pre-
restored teeth when clinical signs and symptoms exist. surgical treatment planning to localize root apex/
n Higher sensitivity and specificity were observed in a apices and to evaluate the proximity to adjacent ana-
clinical study where the definitive diagnosis of vertical tomical structures.
root fracture was confirmed at the time of surgery to
validate CBCT findings, with sensitivity being 88% and Rationale
specificity 75%.19 Several case series studies have con- The use of CBCT has been recommended for treatment
cluded that CBCT is a useful tool for the diagnosis of planning of endodontic surgery.24,25 CBCT visualization of
vertical root fractures. In vivo and laboratory studies the true extent of periapical lesions and their proximity to
evaluating CBCT in the detection of vertical root frac- important vital structures and anatomical landmarks is
tures agreed that the sensitivity, specificity, and accuracy superior to that of periapical radiographs.
of CBCT were generally higher and reproducible.20,21
The detection of fractures was significantly higher for all
CBCT systems when compared to intraoral radiographs. SPECIAL CONDITIONS
However, these results should be interpreted with cau-
tion because detection of vertical root fracture is depen- a. Implant Placement
dent on the size of the fracture, presence of artifacts Recommendation 10: Limited FOV CBCT should be
caused by obturation materials and posts, and the spatial considered as the imaging modality of choice for sur-
resolution of the CBCT. gical placement of implants.26
Recommendation 7: Limited FOV CBCT should be
the imaging modality of choice when evaluating the b. Traumatic Injuries
nonhealing of previous endodontic treatment to Recommendation 11: Limited FOV CBCT should be
help determine the need for further treatment, such considered the imaging modality of choice for diagno-
as nonsurgical, surgical or extraction. sis and management of limited dento-alveolar trauma,
Recommendation 8: Limited FOV CBCT should be root fractures, luxation, and /or displacement of teeth
the imaging modality of choice for nonsurgical re- and localized alveolar fractures, in the absence
treatment to assess endodontic treatment complica- of other maxillofacial or soft-tissue injury that may
tions, such as overextended root canal obturation require other advanced imaging modalities.27
material, separated endodontic instruments, and
localization of perforations. c. Resorptive Defects
Recommendation 12: Limited FOV CBCT is the imag-
Rationale ing modality of choice in the localization and differ-
n It is important to evaluate the factors that impact the entiation of external and internal resorptive defects
outcome of root canal treatment. The outcome predic- and the determination of appropriate treatment and
tors identified with periapical radiographs and CBCT prognosis.28,29
were evaluated by Liang et al.22 The results showed
that periapical radiographs detected periapical lesions in OUTCOME ASSESSMENT
18 roots (12%) as compared to 37 on CBCT scans (25%);
80% of apparently short root fillings based on intraoral Recommendation 13: In the absence of clinical signs
radiographs images appeared flush on CBCT. Treatment or symptoms, intraoral radiographs should be con-
outcome, length and density of root fillings, and out- sidered the imaging modality of choice for the evalu-
come predictors determined by CBCT showed different ation of healing following nonsurgical and surgical
values when compared with intraoral radiographs. endodontic treatment.
n Accurate treatment planning is an essential part of Recommendation 14: In the absence of signs
endodontic retreatment. Incorrect, delayed, or inade- and symptoms, if limited FOV CBCT was the imaging
quate endodontic diagnosis and treatment planning modality of choice at the time of evaluation and

treatment, it may be the modality of choice for 13. Patel S, Dawood A, Mannocci F, et al: Detection of periapical
follow-up evaluation. In the presence of signs and bone defects in human jaws using cone beam computed
tomography and intraoral radiography, Int Endod J 42(6):
symptoms, refer to Recommendation #7. 507–515, 2009.
14. Nixdorf D, Moana-Filho E: Persistent dento-alveolar pain disorder
Rationale (PDAP): Working towards a better understanding, Rev Pain 5(4):
n Use of limited FOV CBCT for evaluation of healing fol- 18–27, 2011.
15. Pigg M, List T, Petersson K, et al: Diagnostic yield of conventional
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Special Committee to Revise the Joint AAE/AAOMR Position Statement on Use of Limited FOV CBCT in Endodontics

Mohamed I. Fayad, Co-Chair, AAE Madhu Nair, Co-Chair, AAOMR

Martin D. Levin, AAE Erika Benavides, AAOMR
Richard A. Rubinstein, AAE Axel Ruprecht, AAOMR
Craig S. Hirschberg, AAE Board Liaison Sevin Barghan, AAOMR

23. Ball RL, Barbizam JV, Cohenca N: Intraoperative endodontic applications

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Radiographic Interpretation

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Radiographic Interpretation

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2 Radiographic

CHAPTER OUTLINE Radiographic Interpretation Diagnosis of Endodontic Treatment

Radiographic Interpretation [MRI]). Interventional and noninterventional imaging mo-

IMAGE CHARACTERISTICS AND PROCESSING

VOXELS AND VOXEL SIZES

Fig. 2.11 ​A, Panoramic 2D image exposed with the

Fig. 2.13 ​CS 9300 3D Extra-Oral Imaging System. (Courtesy Carestream

Fig. 2.14 ​Veraviewepocs 3D R100. (Courtesy JMorita USA, Irvine, CA.)

International, Irvine, CA), default to a 0.4 mm voxel size.

Imaging Tasks Improved or

Fig. 2.19 ​This patient was referred

OVEREXTENDED ROOT CANAL OBTURATION

the maxillary sinus has been reported. Serious conse-

Osteolysis Infraorbital canal Ethmoid air cell

Localized sclerosis Inferior alveolar canal Maxillary sinus

Extraction defect Dilated follicular space

D Inferior alveolar canal E

Superior genial canal

Inferior genial canal

Crestal bone loss

Nasal septum Anterior nasal

Lateral wall of nasal fossa

Inferior nasal conch

Maxillary sinus with mucositis

Nasal fossa Nasal septum

Hard palate Cervical

Opening of incisive canal

Widened apical periodontal U

Buccal cortical plate

Anterior nasal spine

S Palate with torus

Inferior nasal conch Mental foramen

Focal osteoporotic Buccal cortex

C D Initial CBCT 7 year re-evaluation

E Initial CBCT 7 year re-evaluation F Initial CBCT 7 year re-evaluation

G Initial CBCT 7 year re-evaluation H

PA radiography at diagnosing ECR according to the Hei-

Endodontic Treatment Outcomes

Buccal Palatal 0.420 0.420

becoming the standard of care in 3D dentomaxillofacial Magnetic Resonance Imaging

JOINT POSITION STATEMENT OF THE AMERICAN ASSOCIATION

teeth. teeth. The success of nonsurgical root canal therapy

places the patient at risk and may result in unnecessary

Mohamed I. Fayad, Co-Chair, AAE Madhu Nair, Co-Chair, AAOMR

23. Ball RL, Barbizam JV, Cohenca N: Intraoperative endodontic applications

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Fig. 2.11 A, Panoramic 2D image exposed with the

Fig. 2.13 CS 9300 3D Extra-Oral Imaging System. (Courtesy Carestream

Fig. 2.14 Veraviewepocs 3D R100. (Courtesy JMorita USA, Irvine, CA.)

Fig. 2.19 This patient was referred