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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 168-174

Applications and advantages of the use of cone-beam computed tomography in endodontics: An updated literature review


Postgraduate in Dentistry, UCAM, Almeria, Spain

Date of Submission04-Aug-2021
Date of Decision10-Oct-2021
Date of Acceptance11-Oct-2021
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Ana Boquete-Castro
Street Antonio Cano 140, 1st floor. 04009, Almeria
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_167_21

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  Abstract 

Introduction: To assess the potential uses and benefits of cone-beam computed tomography (CBCT) in the field of endodontics, where the anatomy evaluated is complex, and to summarize the possible advantages over two-dimensional (2D) radiography.
Methods: For this study, a review of the literature of the last 13 years was carried out in the PubMed and Google Scholar databases by using the following keywords: CBCT, dental radiography, endodontic diagnosis, management of endodontic problems; 3D imaging. Moreover, inclusion and exclusion criteria were applied.
Results: A total of 29 articles were selected because they fulfilled the inclusion criteria. Articles were analyzed to investigate the advantages, limitations, radiological aspects, and uses of CBCT in endodontics from a critical point of view.
Conclusions: Conventional radiography continues to be the main diagnostic method in endodontics, but taking into account the as low as reasonably achievable principle, in cases in which there are inconclusive signs and symptoms with 2D radiography, CBCT is a useful complement in endodontic diagnosis and allows a more accurate and predictable treatment plan design.

Keywords: Cone-beam computed tomography, dental radiography, endodontic diagnosis, management of endodontic problems, three-dimensional imaging


How to cite this article:
Boquete-Castro A, Lopez AP, Martins AS, Lorenzo AS, Perez PR. Applications and advantages of the use of cone-beam computed tomography in endodontics: An updated literature review. Saudi Endod J 2022;12:168-74

How to cite this URL:
Boquete-Castro A, Lopez AP, Martins AS, Lorenzo AS, Perez PR. Applications and advantages of the use of cone-beam computed tomography in endodontics: An updated literature review. Saudi Endod J [serial online] 2022 [cited 2022 Jul 7];12:168-74. Available from: https://www.saudiendodj.com/text.asp?2022/12/2/168/343550


  Introduction Top


Technology advances rapidly, with improvements in diagnostic techniques that allow us to determine and locate different oral and dental pathologies.[1] Radiography is an essential diagnostic component in dentistry, including endodontics, both for the diagnosis of pulp pathologies, as well as for planning and treatment.[2] However, conventional radiographic techniques have limitations, such as anatomical noise, image overlap, or geometric distortion that cone-beam computed tomography (CBCT) is able to overcome.[3]

Currently, three-dimensional (3D) images of the maxillofacial area are acquired using computed tomography (CT), CBCT, and magnetic resonance imaging (MRI) devices.[4]

CBCT is a technique derived from CT in which a rotary unit is used and an X-ray source and an X-ray detector are fixed on it. The ray-emitting beam is cone-shaped, allowing it to capture information from cylindrical or spherical volumes. As digital images are divided into pixels, the volume acquired by the CBCT is divided into voxels. In essence, a voxel is a 3D pixel. Given that data is captured in volume and not in planes, all voxels are isotropic, which means that all the sides have the same dimensions and a uniform resolution in all directions, allowing clinicians to measure objects accurately and in different directions, which is of great interest for its application in the field of endodontics.[5]

As an added advantage, with the help of the corresponding software, the clinician can observe the subject of study in 2D planes simultaneously in axial, coronal and sagittal views with a range of 0.076 to 2.0 mm or even perform a 3D reconstruction of the subject of study.[6]

CBCT images have a significant effect in determining the etiology of endodontic pathosis, offering clinically relevant information to the specialist which leads to better treatment planning decisions and more predictable results.[7] In addition, this reduces time of exploration and the cost for patients. Furthermore, the amount of radiation exposure is comparable to that received from routine diagnostic images and is significantly less compared to a medical CT.[3] All radiographic examinations must be justified according to individual needs, and although the radiation is reduced, even less than a panoramic one, CBCT is not intended to replace conventional radiography, but to be a complement in order to acquire more diagnostic information.[8],[9] Moreover, its use requires more training and knowledge of anatomy, due to its limitations with high-density objects, since it generates artifacts; as well as taking into account the medical-legal considerations related to the acquisition and interpretation of 3D data.[3] On the other hand, magnetic resonance in recent studies has shown to be a potential means for the diagnosis, prognosis and control in the area of endodontics, with the great advantage of avoiding the risk of ionizing radiation damage. However, it also has disadvantages such as artifacts, the cost, the lack of availability, and the long examination time.[4],[10],[11],[12],[13] The American Association of Endodontics (AAE), the American Association of Oral Maxillofacial Radiology (AAOMR) and the European Society of Endodontics specifically describe the cases in which the use of CBCT with a limited field of vision (FOV) is recommended in order to reduce radiation and scattering artifacts, without forgetting that each exposure must be worth the potential risks.[14],[15]

With this study, the aim was to review in the literature the advantages of CBCT technology with respect to conventional radiography and its applications in the field of endodontics.


  Methods Top


Procedure

The population-intervention-comparison-outcomes question formulated to carry out this systematic review was: Does the use of CBCT achieve a better diagnosis in patients with pathologies of pulp origin or with endodontic problems compared to the diagnosis made exclusively with conventional radiography?

Search strategy

Electronic searches have been carried out in the PubMed, Google Scholar databases. In the PubMed database, the articles between 2007 and 2021 have been selected under the terms MeSH: CBCT AND endodontic diagnosis, CT, cone beam and endodontics, dental radiography, 3D imaging and dental, management of endodontics problems. In Google Scholar, the application of search filters was more limited, consequently articles from the last 14 years were selected with the terms: CBCT endodontic applications, CBCT Endodontic diagnosis, dental radiography, 3D imaging dental, management of endodontics problems. 101,508 articles were identified and 29 were selected according to the following inclusion and exclusion criteria [Figure 1].
Figure 1: Flow chart

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Inclusion criteria

Academic publications with a maximum of 14 years since publication in English, a review articles and the position statements, prospective and retrospective studies, which used the use of CBCT as a diagnostic method.

Exclusion criteria

Articles that have not complied with the aforementioned criteria, duplicate articles or others that have not presented interest or usefulness with the topic to be investigated, articles missing abstracts, articles with incomplete text or with an anonymous author, expert opinions, doctoral theses, and editor's letters.


  Results Top


Advantages of the cone-beam computed tomography

The use of CBCT exceeds the limits of conventional radiography.[16] By reducing noise and artifacts, it allows a more complex appreciation of the anatomy and its spatial relationship with the destruction of bone caused any pathology under study. In addition, the isotropic resolution of the voxels allows for more precise, more accurate, and higher quality images. Exposure to radiation is low, compared to conventional CT scans, and can be even less than a panoramic radiograph,[2] allowing the area of interest to be selected, due to the collimation of the beam of rays. On the other hand, the exploration time is low, like a panoramic X-ray, therefore, in a single rotation all the images can be obtained and through the software the CBCT data can be reconstructed on personal computers, which are low cost and powerful.[2]

Limitations of the cone-beam computed tomography

Very high-density objects such as metal restorations, implants, root fillings, or metal posts produce a hardening of the beam of rays, which generates artifacts in the reconstructed images, and should be considered before performing the CBCT.[2],[17] The exposure time of CBCT devices is around 20 seconds, longer than an intraoral X-ray that is less than 0.35 seconds, which could result in a problem for Parkinson's patients, children or the elderly.[18]

Spatial resolution, even while using the smallest voxel size, may be too low to identify objects such as fractured instruments, difficult to diagnose problems, or incomplete vertical root fractures, but the increase in resolution would lead to an increase in the ionizing radiation absorbed, and therefore harmful.[18]

Radiological aspects

In endodontics, the CBCT units must be of high resolution and a small FOV (less than 5 cm), so there will be less volume of exposed tissue, and thus, the effective dose is reduced, which in turn, reduces dispersion and improves image quality.[19] Each CBCT examination must be adapted to the patient and the diagnostic needs, adjusting the exposure parameters (mA, Kvp, voxel size/exposure time, and number of base images) predetermined by the manufacturer, since effective images must be achieved to improve endodontic diagnosis and treatment.[19]

The mean effective dose has been measured for the large, medium and small FOV of CBCT scans, being 212, 177, and 84 microSv, respectively.[9] Many machines achieve a reasonable exposure of 30 microSv, and a panoramic radiograph produces radiation between 16 and 20 microSv.[9]

Applications of cone-beam computed tomography in endodontics

Root canal treatment evaluation: Anatomy and morphology

Several studies have shown that CBCT is superior in the detection of root canals.[20],[21],[22] Failure of diagnosing root canals can lead to a worse endodontic prognosis.[18],[22] On the other hand, it has been shown that the use of the surgical microscope and CBCT increases the probability of finding more root canals.[18]

The CBCT makes it possible to assess the radius of curvature of the canals, allowing the dentist to choose the most suitable instruments and instrumentation techniques to debride and shape the root canal.[18] In addition to debride and shape, to choose the tool that guarantees more safety and less possibility of iatrogenic errors.[23]

It is considered a valuable tool to evaluate more complex anatomies, which makes it possible to reduce the size of the access cavity to the canal system.[18],[24] Cavity access guides have also been created from the scanning of optical surfaces and CBCT data sets,[25] reducing chair time, iatrogenic damage and allowing the creation of more conservative access cavities that reduce stress for the endodontist.[9] For example, radix molaris is one of the anatomical variants found in a permanent mandibular molar, and 3D imaging techniques based on CBCT are useful for visualizing or studying the true morphology in a noninvasive manner using less radiation.[22]

When canals are identified but are subjected to calcification, intraoperative CBCT has been shown to be useful for assessing the extent of calcification, thereby contributing to determining the proper sequence of the treatment.[26] In addition, it has been reported that conventional periapical radiographs and the dental operating microscope could not provide enough information on the location of calcified canal orifices.[27] Therefore, the intraoperative use of CBCT may be necessary and proved to be vital in successfully locating the calcified canal orifices.[27],[28]

Apical periodontitis detection

Periapical radiography is the standard for the diagnosis of apical periodontitis, but due to the adjacent anatomy, the initial bone destruction is masked.[9],[18],[20],[29] Hence, the lesions can be detected only when the buccal and lingual cortical involvement is presently producing a distinct bone loss (30%–50%) and an area of rarefaction.[20]

However, CBCT has been shown to be able to detect periapical radiolucent areas before they are visible on conventional radiographs and reveal the presence of previously undiagnosed pathology.[2],[9],[17],[18],[20],[29],[30]

A study by Durack and Patel suggested that, if the clinical signs and symptoms of a periapical infection were present but were not conclusive with conventional radiographs, CBCT is a useful adjunct for endodontic diagnosis and its diagnostic accuracy depends on the presence of movement artifacts that today can be reduced with specific systems for this.[24] Other promising modalities such as ultrasound and MRI can also differentiate cysts and granulomas. They have the advantage of being noninvasive diagnostic methods that can be used in vivo.[31],[32],[33],[34] Therefore, early detection of apical periodontitis improves endodontic prognosis, with CBCT being a valuable tool.[24],[29]

Trauma

Radiographic evaluation is essential to make a differential diagnosis of traumatic dentoalveolar injuries, as well as their location and extent. The absence of radiographic signs when the angle of the beam of rays is not parallel to the plane of the fracture, the displacement of the root fracture plane, or the displacement of the teeth and/or fracture of the alveolar bone are one of the limitations of the intraoral radiographs.[2],[4],[5],[18],[20] In horizontal root fractures, the diagnosis consists of locating the fracture line at the level of the apical, middle or cervical third and the degree of dilaceration of the coronal fragment with CBCT being indicated for said diagnosis; otherwise, multiple radiographs would be necessary at different angles and this would pose a significant risk, due to the oblique course of the fracture line in the sagittal plane.[18],[20]

In addition, external inflammatory root resorption is very common sequelae of luxation injury (5%–18%) and avulsion cases (30%). Its diagnosis is based solely on the radiographic demonstration of the process, and CBCT alone can enough for it.[20] Therefore, CBCT helps in the diagnosis, management and improvement of treatment results, assessing the exact nature and severity of the lesions in a single examination.[2],[9],[20]

Presurgical evaluation

For the planning of endodontic surgery, the CBCT is recommended[2],[3],[9],[15],[17],[18],[20] since it allows for the study of the distance between the root and the bone cortex, the location of the maxillary sinus or the assessment of the anatomical relationship of the apices of the roots to the important neighboring structures.[1],[3],[9],[17],[18],[20],[24],[30]

The CBCT helps to detect the lesions that have perforated the sinus floor, the relationship with the inferior dental nerve, the mental foramen, as well as the root morphology and bone typology.[9],[18],[24] It also makes it possible to manufacture surgical guides for tissue retraction and thus facilitate apical surgery.[9],[20]

Evaluation and management of root resorption

Root resorption is a pathological event causing loss of dental hard tissues as a result of osteoclastic activities. Internal root resorption within the root canal is usually asymptomatic and a casual finding on routine radiographic examination often confused and misdiagnosed with external root resorption.[20] The AAE advises performing CBCT for the evaluation and management of root resorption if it appears to be amenable to treatment since conventional radiography underestimates the degree of root injury. These limitations can lead to a misdiagnosis and inadequate management of the same,[9],[20],[35] being corroborated by some studies that confirm the superiority of the CBCT on periapical radiography in external inflammatory resorption[8],[9],[18],[20],[35] and internal root resorption.[8] CBCT can detect small resorptions and early lesions,[18],[20],[35] as well as their volume and linear extension. Therefore, it should be included in the methodology for treatment planning.[18],[20]

Diagnosis of vertical fractures

A vertical root fracture is more common than the horizontal fracture and is characterized by a “through-and-through” crack connecting the pulp space and periodontal ligament. It manifests with nonspecific clinical features such as a localized deep periodontal pocket, sinus tracts, or a lateral radiolucency which complicates the diagnosis if only plain conventional radiographs are used.[18],[20] Clinical signs and symptoms may not be specific, particularly for incomplete fractures.[19]

Some studies affirm that CBCT surpasses conventional radiographs in terms of diagnosis; other studies assure that it depends on the device used.[1],[9],[18]

CBCT may have limitations in detecting vertical root fracture in endodontic teeth since intra-canal filling materials such as gutta-percha reduce their diagnostic ability.[9],[15] Therefore, it is recommended to remove these materials from the root canals prior to imaging with the use of the 0.3 mm voxel protocol, which has a good diagnostic performance and a lower radiation dose.[9],[18]

Evaluation of treatment results

When the disease process is diagnosed by CBCT and the result is evaluated by conventional radiography, it is not possible to have an entirely accurate result, and it may not be as favorable as it seems.[20],[36] Therefore, CBCT is recommended to accurately assess the results of treatment, preparatory examinations, and post-treatment revision scans.[1],[20],[29],[30]


  Discussion Top


Radiography is a vitally important tool in the diagnosis of pulp and periapical pathologies, as well as in planning and treatment. The aim of this systematic review study was to determine the scientific evidence on the advantages of CBCT technology over conventional radiography and its applications in the field of endodontics. Traditional periapical radiograph gives us 2D images of an object that is 3D, which can lead to misinterpretation. The CBCT overcomes these limitations by producing 3D images, which allow us a perfect appreciation of the entire anatomy of the teeth and their relationship with the surrounding skeletal tissues.[1],[18],[24] Quality also depends on the device, the FOV, the size of the voxel, the number of projections, the tube voltage and current, as well as the materials within the canal.[2],[18],[24] Until the year of 2011 there was very little data related to the effect of altering the exposure parameters on the diagnostic performance of the images produced and the effective radiation doses related to the patient; so the scanners were used according to the manufacturer's configuration. There is currently ex vivo evidence suggesting that by altering the degree of rotation of the X-ray source and detector from 360° to 180°, the effective dose is depreciated by half, without reducing the diagnostic performance. The FOV must be limited to the tooth in question.[9],[24],[37] Most endodontic applications only require a small FOV (40 × 40 mm), which depress radiation dose, scan time, and scattering artifacts.

Regarding the applications[2],[3],[17],[18],[19],[20],[21],[22],[24],[30],[37],[38],[39],[40] the CBCT allows for the detection of radiolucent lesions with more accuracy than with conventional radiographs and gives us information on the true state of the periapical tissues.[36] It is a precise, practical, and non-invasive method to reliably assess the size and volume of the bone lesion in all three planes of space. It has benefits in the evolution and treatment of dentoalveolar trauma since it allows us to know exactly the extent of the injuries to the teeth and alveolar bone by eliminating anatomical noise. The CBCT is of great value in analyzing the fracture clearly and allows a 3D reconstruction of the tooth and bone structures. Regarding resorption, the literature justifies the benefit of CBCT scans for a better preparatory evaluation, as well as a better understanding of the pathology, with consequent success in tissue repair.[35] Conventional radiography cannot identify the true extent, location, or gateway of the lesion. However, there is insufficient evidence to defend the use of CBCT in vertical root fractures.

CBCT can give the clinician great help in appreciating the anatomy of the root canal, allowing for more conservative access preparation. It is also very valuable in the study of important anatomical structures and for the evaluation of complex surgical cases, since it offers higher-quality images of teeth, and position of the roots within the bone and vital structures.

Practitioners should not forget that CBCT uses ionizing radiation so it should be handled with caution, and not as a standard method, being limited to cases in which conventional radiography provides us with inadequate information and following the current guidelines recommended by the AAE/AAOMR and the European Society of Endodontics.[8],[14],[18],[19],[37],[41],[42] Dentists must also take into account the medico-legal issues related to the acquisition and interpretation of CBCT images since it requires knowledge and training of anatomy. Dental specialists must not forget that the use of this technology has led to a decrease in surgical treatments as the success rates in endodontics have increased.


  Conclusions Top


Although 3D technology alone does not directly affect the outcome of endodontics, it can lead to better diagnosis, prognostic evaluation, therapy, and therefore, a better outcome. For this reason, the dentist should become familiar with its use and incorporate it into undergraduate and postgraduate programs; judge each case individually and consider CBCT when there are inconclusive signs and symptoms with periapical radiography. Dental community must not forget that they are exposing the patient to ionizing radiation so it must be as low as reasonably possible and that the benefits of an exposure outweigh the potential risks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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