Q U I N T E S S E N C E I N T E R N AT I O N A L

ENDODONTICS

Nestor Cohenca Hagay Shemesh

Clinical applications of cone beam computed

tomography in endodontics: A comprehensive review
Part 1: Applications associated with endodontic treatment and diagnosis

Nestor Cohenca, DDS1/Hagay Shemesh, DMD, PhD2

Cone beam computed tomography (CBCT) is a new technology ment can be obtained for diagnosis and treatment. This com-
that produces three-dimensional (3D) digital imaging at prehensive review presents current applications of CBCT in
reduced cost and less radiation for the patient than traditional endodontics. Specific case examples illustrate the difference in
CT scans. It also delivers faster and easier image acquisition. By treatment planning with traditional periapical radiography
providing a 3D representation of the maxillofacial tissues in a versus CBCT technology. (Quintessence Int 2015;46:465–480;
cost- and dose-efficient manner, a better preoperative assess- doi: 10.3290/j.qi.a33990)

Key words: 3D, cone beam computed tomography, endodontics, root canal therapy

Periapical (PA) radiographs combined with clinical tial diagnosis of apical periodontitis, often in cases
examination have long been the standard for endodon- where there is no evidence of pathosis identified by
tic diagnosis and postoperative evaluation of healing. conventional imaging.4 This advantage is reflected in
However, PA radiographs only provide a two-dimen- the increased overall sensitivity of 1.0 for CBCT (125 μm
sional (2D) view of three-dimensional (3D) structures. voxel) compared with 0.248 for intraoral 2D radiog-
Classic studies by Seltzer et al1,2 showed that erosion of raphy for diagnosis of PA lesions. Both imaging modal-
junctional bone is necessary for radiographic detection ities have specificity values of 1.0.5 Accordingly, the
of bony destruction. Bender3 later estimated that 7.1% incidence of apical periodontitis is increased when
mineral bone loss in cortical bone is required to pro- roots are assessed with CBCT compared to assessment
duce a radiolucent area when accounting for soft tissue with PA radiographs.6
absorption. While there is no debate about the benefits of CBCT
Cone beam computed tomography (CBCT) is a rela- in endodontics, all clinicians must consider the princi-
tively new technology currently available in endodon- ple of ALARA (As Low As Reasonably Achievable) when
tic practice. Among the many uses of CBCT is differen- using CBCT and any other imaging technology. In order
to minimize radiation exposure while maximizing diag-
1 Private Practice, Seattle, WE, USA; and Affiliate Professor, Department of Pediat- nostic information, clinicians should consider the use of
ric Dentistry, School of Dentistry, University of Washington, Seattle, WA, USA. CBCT only when the need for imaging cannot be
2
Associate Professor, Section for Endodontology, Academic Center for Dentistry
Amsterdam (ACTA), Amsterdam, The Netherlands.
answered adequately by lower dose conventional den-
tal radiography or alternative imaging modalities.
Correspondence: Dr Nestor Cohenca, 16633 NE 40th CT. Redmond, WA
98052-5245, USA. Email: [email protected] Therefore, it is important to consider the effective dose

VOLUME 46 • NUMBER 6 • JUNE 2015 465

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

of various imaging modalities and their resolution in and assessment of the outcome of endodontic compli-
relation to the information they provide to the clinician. cations.11 Authors concluded that CBCT imaging should
In 1991, Fryback and Thornbury7 presented a gen- be considered in situations in which information from
eral hierarchical model of diagnostic imaging efficacy conventional imaging systems may not yield an ade-
that can be used for classification of assessment stud- quate amount of information to allow the appropriate
ies. Demonstration of efficacy at each lower level in this management of endodontic problems. The purpose of
hierarchy is logically necessary, but not sufficient, to this manuscript is to review and discuss the endodontic
assure efficacy at higher levels. Level 1 concerns techni- applications of CBCT in diagnosis, treatment planning,
cal quality of the images; level 2 addresses diagnostic and outcome of endodontic therapy.
accuracy, sensitivity, and specificity associated with
interpretation of the images. Next, level 3 focuses on
whether the information produces change in the refer-
EVALUATION OF ANATOMY AND
ring physician’s diagnostic thinking. Such a change is a
COMPLEX MORPHOLOGY
logical prerequisite for level 4 efficacy, which concerns 3D evaluation of maxillofacial structures should be con-
the effect on the patient management plan. Level 5 sidered in cases of anatomical variations and complex
efficacy studies compute the effect of the information morphology. The use of CBCT is a critical diagnostic
on patient outcomes. Level 6 analyses examine societal tool to determine the anatomy, etiology, and develop-
costs and benefits of a diagnostic imaging technology. ment of the best and most conservative treatment
A key feature of this model is the understanding that plan.
for an imaging procedure to be efficacious at a higher
level in this hierarchy, it must be efficacious at lower Anatomical anomalies
levels, but the reverse is not true. Efficacy of diagnostic One of the most common and challenging anatomies
imaging is complicated by the fact that imaging is one for endodontic treatment is dens invagination, com-
step in a larger process and there are many points in monly known as “dens in dente”. Dens invaginatus is a
this process to measure the information transmitted or developmental malformation of teeth, showing a wide
the effects of the information on the process. Only by spectrum of anatomical variations. The anatomical
examining the full continuum do we begin to see the anomaly was first described in 1855 by Salter as “a
interrelationships and the limitations as well as tooth within a tooth”.12 This developmental malforma-
strengths of each study design. tion is more common than we normally believe.
Different studies have shown that field size (small, According to the literature, the frequency varies from
medium, and large) is directly correlated to the effec- 0.04% to 10%,13 and the most affected permanent teeth
tive dose.8,9 The average doses for large, medium, and are the maxillary lateral incisors, frequently bilateral
small fields of view (FOVs) were 131, 88, and 34 μSv re- (43%),14 followed by central incisors, canines, pre-
spectively.8 Thoughtful selection of the FOV, region of molars, and molars.15
interest, and resolution is needed to optimize diagnos- Dens invaginatus teeth are prone to early develop-
tic information and to reduce patient dose. In end- ment of caries and subsequent necrosis of the pulp. As
odontics, the need for high-resolution images may a matter of prevention, prophylactically sealing the
require higher radiation. Thus, the indications for 3D invagination with resins is strongly encouraged.16 In
imaging in endodontics should be fully justified over cases in which the bacterial invasion has reached the
conventional 2D imaging, particularly in children.10 pulp and necrosis is established, nonsurgical root canal
Recently, Venskutonis et al11 published a compre- treatment remains the treatment of choice (Fig 1).
hensive review of the literature to evaluate the use of Depending on the type of malformation and the com-
CBCT imaging in the diagnosis, treatment planning, munication of the invagination with the pulp, end-

466 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

a b c

d e f g
Figs 1a to 1g Dens invagination type III. Axial, sagittal, and coronal slides demonstrate the complexity of the anatomy. Based on the
data obtained from the CBCT, the internal anatomy was modified and the endodontic therapy completed successfully.

Preoperative at 125 μm

3.0 mm
5.0 mm
6.7 mm
2.1 mm

a b c d

Postoperative follow-up at 76 μm

e f g h

Figs 2a to 2h Dens invagination type II. (a) Preoperative PA radiograph failed to demonstrate the accurate source of contamination.
(b to d) The CBCT taken illustrated that the contamination was limited to the dens and the subsequent apical periodontitis on the
mesiobuccal aspect of the root. Note that the apical area shows an undisrupted lamina dura and no lucencies. (e to h) Three-month
follow-up demonstrating healing of the lesion on all planes.

odontic therapy may be confined to the invagination The successful management of a dens invaginatus
with the subsequent preservation of pulp vitality.17,18 In starts by providing an early diagnosis and protection of
most cases the endodontic treatment must include the unprotected dentin. In cases in which the pulpal
both the invagination and the root canals (Fig 2).19,20 complex has been exposed to microbial contamination,

VOLUME 46 • NUMBER 6 • JUNE 2015 467

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

regards to its root and root canal anatomy, thus neces-

sitating critical evaluation of each individual case for
variations.24-28
Silva et al29 published a comprehensive 3D evalu-
ation of 460 healthy, untreated, fully developed man-
dibular first molars and showed a higher prevalence of
two canals in the mesial root and one in the distal root
with two separate roots (74%). In the mandibular sec-
ond molars, the presence of two separate roots with
a b two canals in the mesial root and one canal in the distal
Figs 3a and 3b C-shaped canals on the mandibular first (a) and root represented 54%. In 32% of the cases, two sepa-
second (b) molars. rate roots with one canal each in the mesial and distal
roots were present. A lower incidence of C-shaped
the use of CBCT becomes an important diagnostic tool canals and three-rooted teeth were observed in a Bra-
in determining the anatomy as well as the level of con- zilian population (Fig 3).29
tamination and type of treatment to be provided. In The same group of researchers evaluated the anat-
cases in which the infection remains limited to the omy of 620 healthy, untreated, fully developed maxil-
invagination, thorough disinfection of the contami- lary first and second molars.30 First and second molars
nated space results in periradicular healing while pre- showed a higher prevalence of three separate roots
serving a vital pulp in the main canal. Given the signifi- (mesiobuccal, distobuccal, and palatal) with one canal
cant variations in available resolution within CBCT in each root (52.87% and 45.09% respectively). Two
devices, one should assess whether the resolution that canals in the mesiobuccal roots represented 42.63% of
may be adequate for oral and maxillofacial surgical the teeth while mesiobuccal roots of second molars
planning is adequate for specific determination of ana- presented two canals in 34.32%. The most common
tomical features as in dens invaginatus. Recently, Kfir et anatomical variation in the maxillary first molar was
al21 reported the use of 3D plastic models, printed from related to the root canal configuration of the mesiobuc-
CBCT data, for accurate diagnosis and conservative cal root, while the root canal system of the maxillary
treatment of a complex case of dens invaginatus. This second molar teeth showed more anatomical variation
approach allowed the vitality of the pulp to be main- (Fig 4).
tained in the complex root canal space of the main root Failing to understand the internal endodontic anat-
canal whilst enabling the healing of the PA tissues. omy of the root canal system is directly correlated to
the outcome of the treatment (Fig 5).
Missed/accessory canals
The complexity of root canal systems and internal mor- Additional roots
phology has been directly correlated with endodontic Abella et al31 presented a case of a mandibular first
treatment planning, therapy, and outcome. Mandibular molar with an additional distolingual root radix ento-
first molars are the first permanent teeth to erupt, often molaris (RE), and concluded root canal treatment in
requiring endodontic care due to early caries.22 Typi- teeth with extra roots can be challenging, but the
cally, mandibular molars present with two well-defined inability to find root canals may cause failures. CBCT
roots: a mesial root characterized by a flattened mesio- images can result in a better understanding of root
distal surface and widened buccolingual surface, and a canal anatomy, which enables the clinician to evaluate
distal root mostly straight with a wide oval canal or two the root canal system and to clean, shape, and fill it
round canals.23 However, many variations exist in more efficiently.

468 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

a b c

a b

12.0 mm

d e f

c d
Figs 5a to 5d Endodontic failure, possibly caused by a second
Figs 4a to 4g Anatomical variations of mesiobuccal canal left untreated. Note the sinus mucositis related
g maxillary second molars. to the apical periodontitis (arrow).

a b c d
Figs 6a to 6d Maxillary left lateral incisor with a very uncommon root extension on the mesiolingual aspect of the root. This anatom-
ical anomaly was causing a periodontal abscess.

Additional roots might be present in more eccentric pulp with normal apical tissues. Further evaluation
places that are impossible to diagnose using plain 2D using CBCT demonstrated the source of infection,
radiographs. A good example of this clinical situation which was not related to the pulp or any endodontic
illustrated in Fig 6. A 43-year-old woman was referred pathology. The abscess was periodontal and related to
for a root canal treatment on her maxillary left lateral the presence of a root extension on the mediolingual
incisor due to a dental abscess, as diagnosed by the aspect of the root. Accordingly, the patient was referred
Oral Medicine department. Initial clinical and radio- to a periodontist for surgical removal and planning
graphic examination revealed the presence of a vital (Fig 6).

VOLUME 46 • NUMBER 6 • JUNE 2015 469

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

DIFFERENTIAL DIAGNOSIS on PA radiographs and CBCT shows that we can rely

with some confidence on the chief complaint in deter-
The term diagnosis is derived from the Greek words dia mining the need for CBCT as an adjunct for an end-
(through) and gnosis (knowledge). It is the determina- odontic diagnostic exam.
tion of the nature of a diseased condition by careful Patel et al32 assessed 273 paired roots with both
investigation of the symptoms and history. Although radiologic systems. PA lesions were present in 55 (20%)
diagnostic testing of some common complaints may and absent in 218 (80%) roots assessed with PA radio-
produce classic results, occasionally testing will pro- graphs. When the same 273 sets of roots were assessed
duce inconsistent or incomplete results that need to be with CBCT, lesions were present in 130 (48%) and
carefully interpreted by the astute and curious clinician absent in 143 (52%) roots. Seventy-five additional roots
to resolve discrepancies. were detected with CBCT.
3D imaging technology allows clinicians to deter- Figure 7 presents a case of a 23-year-old woman
mine not only the anatomy, but also the presence of with history of dental trauma causing luxation of the
disease and the probable reason. CBCT imaging has maxillary left central incisor. Endodontic therapy was
provided clinicians with the data required to formulate completed but the chronic pain persisted. No radio-
more predictable treatment plans, making the need for graphic findings were found to justify treatment. Only
an exploratory flap operation obsolete. after 1 year with no resolution of the symptoms was a
CBCT was taken, revealing the real etiology of the pain.
Contradictory or nonspecific clinical signs A bone fenestration with exposed apex was diagnosed
and symptoms and treated surgically with guided tissue regeneration
Patients often present with complex symptomatology (GTR). Symptoms resolved immediately after therapy.
and undetermined etiology. Sometimes, these “idio- The 1-year follow up CBCT and clinical images demon-
pathic pain” cases require medications. With today’s strated the formation of a new cortical plate.
knowledge and technology, the amount of undiag-
nosed cases had been reduced dramatically. Poor localized symptoms associated with an
Weissman and coworkers (Weismann J, unpub- untreated or previously endodontically
lished data, 2015) developed a clinical study to corre- treated tooth with no evidence of pathosis
late the incidence of apical periodontitis evaluated with In a population-based study in the UK, using a postal
2D PA radiographs and 3D CBCT volumes with clinical questionnaire, Aggarwal et al33 evaluated the co-occur-
signs and symptoms. Of 498 cases, 75 fulfilled the inclu- rence of four frequently unexplained syndromes (chronic
sion criteria and were evaluated for apical periodontitis widespread pain, chronic orofacial pain, irritable bowel
and symptomology. syndrome, and chronic fatigue) and whether there are
Thirty-eight of 67 teeth showed the presence of api- common factors associated with the reporting of these
cal radiolucencies on PA radiographs and on CBCT, syndromes. It is important to remember that every long-
whereas 14 teeth had no evidence of apical radiolucen- term condition associated with pain results in psychologic
cies on PA radiographs or on CBCT. Fifteen cases morbidity and reduced quality of life. It is being increas-
showed the presence of apical radiolucencies visible on ingly recognized that some patients have an increased
CBCT that were not visible on PA radiographs. This risk of developing chronic facial pain,34 and recognizing
research has important implications to prevent over- this group early may reduce multiple referrals and inap-
treatment, and to provide treatment for those patients propriate management. Moreover, it is known that pre-
with persistent symptoms lacking proper diagnosis dictors of poor outcome can be identified early.35,36
based on conventional (2D) radiographs. The correla- Apical periodontitis could often be the etiology
tion between patients’ chief complaints and findings related to undiagnosed chronic pain. However, we

470 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

a b c d
Figs 7a to 7d Maxillary left central incisor. (a and b) The tooth was endodontically treated due to a traumatic injury. The patient
remained symptomatic with no evidence of pathology. CBCT study revealed the presence of a bone fenestration with lack of cortical
bone covering the apex of the tooth. (c and d) One-year follow-up after guided tissue regeneration surgery.

16.1 mm

10.7 mm

a b c

Figs 8a to 8e (a and b) Two PA radiographs taken at different

angles, failed to demonstrate a clear pathology on the patient’s
maxillary left second premolar as well as the first and second
molars. (c to e) The 3D scan revealed the presence of apical peri-
odontitis in relationship with her maxillary left first molar as well
d e
as a severe mucositis on the maxillary sinus.

sometimes fail to reach a definitive diagnosis and treat- examined her and could not diagnose any endodontic
ment plan due to the fact that our evaluation is based reason in relation to her symptoms. Upon clinical exam-
on 2D imaging. A good example of this clinical chal- ination all three teeth were sensitive to percussion and
lenge is presented in Fig 8. A 45-year-old woman pre- palpation. There was no difference in type or intensity of
sented with chronic pain in the maxillary left premolar. pain between them. Two PA radiographs, taken at differ-
Her maxillary left second premolars as well as the first ent angles, failed to demonstrate a clear pathology
and second molars were endodontically treated by an (Figs 8a and 8b). A CBCT was taken for further diagnosis.
endodontist more than 3 years previously. Her chief The data obtained were consistent with the presence of
complaint was mild to moderate pain on her left maxilla. apical periodontitis in relationship with her maxillary
Dental history revealed that three different endodontists first left molar. The scan also revealed a severe mucositis

VOLUME 46 • NUMBER 6 • JUNE 2015 471

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

on the maxillary sinus (Figs 8c to 8f). The recommended cerning the accuracy and effectiveness of clinical and
treatment included nonsurgical root canal retreatment, radiographic dental evaluation for the diagnosis of VRF
aimed at treating the space of infection. The patient’s in endodontically treated teeth were lacking. Numer-
pain subsided a few days after therapy. ous case reports and ex vivo and clinical studies have
investigated the ability of CBCT to diagnose VRF.
Non-odontogenic The first to investigate the ability of CBCT to diagnose
In a different case, a patient was referred for endodon- VRF were Hassan et al,40 who found that the accuracy of
tic retreatment of the maxillary right central incisor. CBCT for detecting simulated VRFs in root filled and non-
Further diagnosis with 3D imaging revealed a non- root-filled teeth was significantly higher than PA radio-
odontogenic pathology. After excisional biopsy and graphs, 0.86 and 0.66, respectively. The presence of a
histology the lesion was diagnosed as a nasopalatine root filling reduced sensitivity and accuracy of radio-
duct cyst (Fig 9). graphs, and reduced the specificity of CBCT. Other ex
vivo studies have also concluded that CBCT is more accu-
Odontogenic rate than PA radiographs for the diagnosis of VRF.41,42
Odontogenic infections are a common cause of maxil- Some authors suggest that the higher accuracy of
lary sinusitis. 2D images are unable to allow a definitive CBCT in detecting VRF in the above studies might be
diagnosis in these cases. Since the development and due to the simulated fractures being wider than natu-
implementation of CBCT, it has become obvious that rally occurring fractures.43,44 These studies used a differ-
many root canal infections and PA lesions are directly ent model to induce incomplete fractures and larger
related to changes on the maxillary sinus. Shanbhag et fractures in sound43 and root-filled teeth,44 and found
al37 evaluated the relationship between teeth with PA that the overall accuracy for detecting fractures was
lesions or periodontal disease and sinus mucosal thick- 0.87 and 0.45 for non-root-filled teeth and root-filled
ening using CBCT imaging.37 Scans of 243 patients (485 teeth respectively with CBCT, and 0.63 and 0.53 for
sinuses) were evaluated retrospectively for the pres- non-root-filled teeth and root-filled teeth respectively
ence of PA lesions and/or periodontal disease in poste- with radiographs.
rior maxillary teeth and associated sinus mucosal thick- The accuracy of CBCT for the detection of VRF also
ening. Thickening > 2 mm was considered pathologic appears to be dependent on the CBCT device used.45-47
and was categorized by degree (2 to mm, 5 to 10 mm, This may be due to several factors including differences
and > 10 mm) and type (flat or polypoid). Their results in exposure parameters, detector sensitivity, voxel set-
confirmed that sinus mucosal thickening, also called tings, and reconstruction algorithms. The presence of
mucositis, is a common radiographic finding, which is metallic posts did not significantly interfere with the
more likely to be observed in males (2 ×) and in relation detection of VRF in in vitro studies.48,49
to teeth with PA lesions (9.75 ×) (Fig 10). Several case (series) reports have concluded CBCT is
Recently, Jiang et al38 illustrated characteristic fea- useful for the diagnosis of VRF. Wang et al42 investi-
tures of adenomatoid odontogenic tumor (AOT) using gated 128 patients with clinically suspected root frac-
CBCT and concluded that when compared with pan- tures in 135 teeth of which 49 were root-filled. Radio-
oramic radiography, CBCT seems to possess better graphs and CBCT were taken and compared with
potential in diagnosing AOT. findings from surgical exploration. The sensitivity of
CBCT scans in diagnosing VRF was found to be 89.5.
Vertical root fractures Edlund et al50 found similar sensitivity values by inves-
Vertical root fractures (VRF) might have devastating tigating 32 teeth with clinical signs and symptoms sug-
effects on the affected tooth. In a systematic review, gestive of VRF. A good representation of a clinical case
Tsesis et al39 concluded that evidence-based data con- is illustrated in Fig 11.

472 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

b c

a d e
Figs 9a to 9e The patient referred for endodontic retreatment of the maxillary right central incisor. (a) The PA radiograph demonstrates
an apical lucency. However, the lamina dura seems undisrupted. (b to e) Further imaging confirmed the suspicion of a non-odontogen-
ic pathology, later diagnosed as a nasopalatine duct cyst.

a b c

12.0 mm

d e f
Figs 10a to 10f Endodontic infection on the maxillary right first molar causing apical periodontitis and mucositis on patient’s maxil-
lary sinus (arrows).

VOLUME 46 • NUMBER 6 • JUNE 2015 473

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

Metska et al51 investigated 39 patients with end- resulted in 68% healing of apical periodontitis. On the
odontically treated teeth with suspected VRF where no other hand, inadequate root-filling length resulted in
fracture line could be detected on the radiograph. They 84% healing. Analytic interpretation of these data dem-
found a sensitivity of 93% for the Accuitomo 170 CBCT onstrates that when we know the reason for the failure
scans (Morita) in diagnosing a VRF. of the initial root canal treatment (ie, inadequate root-
The conclusions of these clinical studies should be filling length), our outcome is higher. Why did we fail
interpreted with caution since the observers’ initial on those teeth with adequate root-filling length? Most
diagnosis is usually influenced by adjacent alveolar probably because we do not understand the reason or
bone loss, and bias is unavoidable. Moreover, only etiology of the failure! We cannot “fix a problem” if we
teeth with suspected VRF are investigated, again lead- do not know what and where it is located. CBCT pro-
ing to bias, as there were no controls. Numerous ex vides us with an accurate preoperative diagnosis, iden-
vivo studies and in vivo reports have concluded that tifying the etiology and location of the source of infec-
CBCT is able to diagnose VRF in root-filled teeth. How- tion. For root canal retreatment, understanding the
ever, laboratory simulated VRFs in some of these stud- etiology of the disease or failure is critical to obtaining
ies are not always clinically relevant due to their size a positive outcome. Fig 12 illustrates the case of a
and extent, and clinical studies were not controlled. symptomatic patient in which the initial root canal
More clinical studies are required to quantify and assess therapy seems adequate, even after exposing the
the value of CBCT in diagnosing root fractures, espe- patient to four PA radiographs, at different angles. A
cially in root-filled teeth. Corbella et al52 conducted a CBCT scan revealed the presence of apical periodontitis
systematic review of the literature and meta-analysis to in the distobuccal and distolingual roots (Fig 13). Ther-
compare the efficiency of CBCT and conventional intra- apy was aimed at eliminating the source of infection
oral radiography for the detection of VRF. No superior- and healing of the apical periodontitis. The treatment
ity of CBCT compared with conventional radiography was deemed successful and the patient was asymp-
was found for VRF detection. It is important to remem- tomatic on the follow-up examinations (Fig 14).
ber that the diagnosis of VRF is made from clinical and
radiographic findings alike. The combination of clinical
observations like deep pocket, a sinus tract, the pres-
PRESURGICAL CASE PLANNING
ence of a post, or the type of tooth involved would Endodontic surgery is performed when a good quality
supplement the radiographic findings to reach a diag- root canal treatment has failed and nonsurgical retreat-
nosis. ment cannot be performed.54 When a surgical pro-
cedure is being considered, the operator could utilize
extra information like fine anatomical structures, num-
NONSURGICAL ROOT CANAL ber of canals, canal morphology, quality of the existing
RETREATMENT root canal filling, position of intracanal posts, perfor-
Nonsurgical and surgical endodontic retreatment ations, resorptions, and extent and location of the PA
should be treatment planned and performed according lesions in order to facilitate the surgical treatment and
to the specific goals of the treatment. In 2010, Barone minimize complications. The advantage of a preopera-
et al53 reported the results of a 4- to 10-year cohort tive CBCT evaluation was recently shown to have a
study aiming to identify significant outcome predictors. positive impact on treatment outcomes of PA surgery.55
Endodontics outcome was better in subjects > 45 years All phases of the surgical treatment could benefit from
old, teeth with inadequate root-filling length, and crypt CBCT imaging: diagnosis, pretreatment planning, and
size of ≤ 10 mm. Specifically, when the preoperative assessment of outcome.
root-filling length was adequate, the retreatment

474 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

a b c

d e f
Figs 11a to 11f (a and b) The patient presented with a sinus tract traced to the maxillary right first premolar. (c) A nonsurgical root
canal retreatment was performed but the patient returned after 2 months with a recurrent sinus tract. (d and e) A CBCT scan revealed
the presence of a VRF on the lingual surface. (f) The tooth was extracted and the fracture confirmed.

a b c d
Figs 12a to 12d Four PA radiographs of the mandibular first right molar, taken at different angles. No lucency or evidence of apical
periodontitis.

The advantage of CBCT on PA radiographs in gener- radicular cysts from granulomas. Obviously, more clin-
ating reliable information on the anatomy of the ical research is needed in order to clarify the ability of
treated tooth, presence of PA lesion, and complications CBCT to differentiate a PA cyst from a granuloma. CBCT
such as resorption or trauma were previously discussed was shown to be more useful for the diagnosis of odon-
in this review. The differential diagnosis of granuloma togenic keratocycsts compared to panoramic radio-
or cyst could indicate if a surgical approach should be graphs.59
attempted. Although an apical cyst could not prevent The axial, coronal, and sagittal planes obtained with
healing after nonsurgical root canal treatment, a surgi- CBCT scans allow for a better interpretation and diag-
cal approach could result in faster healing.56 In 2006, nosis of the PA lesion in relation to adjacent structures,
Simon et al57 concluded that CBCT may provide a more and reliable assessment of its size and extension. The
accurate diagnosis than biopsy and histology regarding distance from the lesion to the mandibular canal and
the differential diagnosis of a PA granuloma or cyst. alveolar bone surface,60 the proximity to the maxillary
However, Rosenberg et al58 found that CBCT imaging is sinus,61 and potential complications such as strip per-
not a reliable diagnostic method for differentiating forations62 and resorptions63 could influence the clinical

VOLUME 46 • NUMBER 6 • JUNE 2015 475

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

a b c

4.7 mm

2.3 mm
1.4 mm
5.0 mm
3.1 mm

d e f
Figs 13a to 13f (a to c) CBCT images demonstrated a normal lamina dura on the mesial root of the mandibular right first molar. (d)
Evaluation of the distal roots demonstrated the presence of apical periodontitis on the distobuccal and distolingual (e and f).

a b
Figs 14a and 14b (a) Preoperative and (b) postoperative PA radiographs of the mandibular right first molar.

procedure and are important factors to consider before The healing of PA lesions is more accurately
treatment. Furthermore, the size of the lesion could aid assessed with CBCT compared to radiographs.64 Tano-
in planning the surgical approach, flap design, and pos- maru-Filho et al65 evaluated the dynamics of PA repair
sible complications.61 after endodontic surgery. Scans were taken preopera-

476 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

17.1 mm

12.1 mm
17.8 mm

a b c d
Figs 15a to 15d (a) The patient presented for surgical retreatment (apical surgery) of the mandibular left first molar. Medical history
disclosed ovarian cancer. An excisional biopsy was indicated. However, the size and location of the lesion was a concern due to its
proximity to the inferior alveolar canal. (b and c) The CBCT was important to determine the anatomical boundaries to avoid pressure
and/or injury to the nerve. (d) Three month follow-up showing evidence of initial healing (note the presence of a lamina dura). The
patient did not develop any signs of paresthesia. The pathology report diagnosed the lesion as an apical cyst.

tively, intraoperatively, immediately after surgery, and treatment plan allows for adjustments to the treatment
4 and 8 months after the procedure. They concluded plan and implementation so as to avoid many compli-
that a longer follow-up period was needed in order to cations. Although 3D technology by itself will not
assess healing after PA surgery and that PA lesions may directly affect endodontic outcome, it might lead to
be repaired with fibrous tissue rather than mineralized better therapeutics that will eventually improve the
bone tissue. CBCT showed less bone repair compared outcome.
to radiographs in the later repair stages. The absence of highly prospective randomized clin-
A preoperative CBCT scan could serve as a compli- ical trials underlines the need for further research on
mentary modality that provides valuable information the treatment outcomes related to CBCT applications in
on anatomy and adjacent structures before attempting endodontic therapy. Limited FOV CBCT imaging seems
PA surgery (Figs 15 to 17). Recently, Kurt et al55 pub- to be generally advantageous in the diagnosis, assess-
lished the results of a prospective, randomized, con- ment of prognosis, and treatment planning, but more
trolled, clinical study comparing the outcome of peri- clinical studies are warranted to determine the exact
radicular surgery between two preoperative radiologic impact on outcomes.
evaluation methods: CBCT and conventional radiog- Diagnosis is based on multifactorial data that
raphy. The mean operative time was significantly include imaging, as well as a thorough clinical examin-
shorter in the CBCT group. They concluded that preop- ation. There is no one single test or imaging technology
erative CBCT examination demonstrated positive con- that will provide a definitive diagnosis. A risk/benefit
tributions to the treatment outcomes. analysis should always be considered prior to any imag-
ing technique. Optimization of dose should be per-
formed by an appropriate selection of exposure param-
DISCUSSION eters and field size, depending on the diagnostic
CBCT technology could be beneficial for most special- requirements. Evaluation of CT, or of any dynamic
ties in dentistry. In endodontics, the clinical applica- medical technology, will never provide final answers.66
tions of 3D imaging illustrated in this review demon- At this time, intraoral radiography is the imaging tech-
strate the broad spectrum and the critical information nique of choice for the management of endodontic
obtained. disease. Diagnosis and treatment planning should be
CBCT provides a more truthful diagnosis of apical obtained based on a comprehensive clinical and
periodontitis, as demonstrated in several in vivo stud- radiographic evaluation.
ies.31,32,63 Accurate diagnosis followed by a predictable

VOLUME 46 • NUMBER 6 • JUNE 2015 477

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

Figs 16a to 16e (a and b) Diagnostic radiograph and image of a mandibular premolar
with a failed root canal treatment. (c to e) CBCT images of the same tooth as preparation
for apical surgery. (Courtesy of Dr Miguel Seruca Marques, Amsterdam.)

a b

c d e

a b c

Figs 17a to 17e (a to c) Surgical proced-

ure. (d and e) Postoperative and 1-year
follow-up. (Courtesy of Dr Miguel Seruca
d e Marques, Amsterdam.)

478 VOLUME 46 • NUMBER 6 • JUNE 2015

 Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

REFERENCES 25. de Pablo OV, Estevez R, Peix Sanchez M, Heilborn C, Cohenca N. Root anatomy
and canal configuration of the permanent mandibular first molar: a system-
1. Seltzer S, Bender IB, Ehrenreich J. Incidence and duration of pain following atic review. J Endod 2010;36:1919–1931.
endodontic therapy. Relationship to treatment with sulfonamides and to 26. Song JS, Choi HJ, Jung IY, Jung HS, Kim SO. The prevalence and morphologic
other factors. Oral Surg Oral Med Oral Pathol 1961;14:74–82. classification of distolingual roots in the mandibular molars in a Korean popu-
2. Seltzer S, Bender IB, Kaufman IJ. Histologic changes in dental pulps of dogs and lation. J Endod 2010;36:653–657.
monkeys following application of pressure, drugs, and microorganisms on 27. Chandra SS, Chandra S, Shankar P, Indira R. Prevalence of radix entomolaris in
prepared cavities. II. Changes observable more than one month after applica- mandibular permanent first molars: a study in a South Indian population. Oral
tion of traumatic agents. Oral Surg Oral Med Oral Pathol 1961;14:856–867. Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e77–e82.
3. Bender IB. Factors influencing the radiographic appearance of bony lesions. J 28. Kim SY, Yang SE. Cone-beam computed tomography study of incidence of
Endod 1982;8:161–170. distolingual root and distance from distolingual canal to buccal cortical bone
4. Goldman M, Pearson AH, Darzenta N. Reliability of radiographic interpreta- of mandibular first molars in a Korean population. J Endod 2012;38:301–304.
tions. Oral Surg Oral Med Oral Pathol 1974;38:287–293. 29. Silva EJ, Nejaim Y, Silva AV, Haiter-Neto F, Cohenca N. Evaluation of root canal
5. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical configuration of mandibular molars in a Brazilian population by using cone-
bone defects in human jaws using cone beam computed tomography and beam computed tomography: an in vivo study. J Endod 2013;39:849–852.
intraoral radiography. Int Endod J 2009;42:507–515. 30. Silva EJ, Nejaim Y, Silva AI, Haiter-Neto F, Zaia AA, Cohenca N. Evaluation of
6. Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis root canal configuration of maxillary molars in a Brazilian population using
using periapical radiography and cone beam computed tomography: part 1: cone-beam computed tomographic imaging: an in vivo study. J Endod
pre-operative status. Int Endod J 2012;45:702–710. 2014;40:173–176.
7. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decision 31. Abella F, Mercade M, Duran-Sindreu F, Roig M. Managing severe curvature of
Making 1991;11:88–94. radix entomolaris: three-dimensional analysis with cone beam computed
8. Pauwels R, Beinsberger J, Collaert B, et al. Effective dose range for dental cone tomography. Int Endod J 2011;44:876–885.
beam computed tomography scanners. Eur J Radiol 2012;81:267–271. 32. Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis
9. Qu XM, Li G, Ludlow JB, Zhang ZY, Ma XC. Effective radiation dose of ProMax using periapical radiography and cone beam computed tomography - part 1:
3D cone-beam computerized tomography scanner with different dental pro- pre-operative status. Int Endod J 2012;45:702–710.
tocols. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:770–776. 33. Aggarwal VR, McBeth J, Zakrzewska JM, Lunt M, Macfarlane GJ. The epidemi-
10. Theodorakou C, Walker A, Horner K, et al. Estimation of paediatric organ and ology of chronic syndromes that are frequently unexplained: do they have
effective doses from dental cone beam CT using anthropomorphic phan- common associated factors? Int J Epidemiol 2006;35:468–476.
toms. Br J Radiol 2012;85(1010):153–160. 34. Aggarwal VR, Macfarlane GJ, Farragher TM, McBeth J. Risk factors for onset of
11. Venskutonis T, Plotino G, Juodzbalys G, Mickeviciene L. The importance of chronic oro-facial pain: results of the North Cheshire oro-facial pain prospec-
cone-beam computed tomography in the management of endodontic prob- tive population study. Pain 2010;149:354–359.
lems: a review of the literature. J Endod 2014;40:1895–1901. 35. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV. Predictors
12. Salter S. Warty tooth. Trans Pathol Soc Lond 1855;6:173–177. of outcome for orofacial pain in the general population: a four-year follow-up
13. Hovland EJ, Block RM. Nonrecognition and subsequent endodontic treat- study. J Dent Res 2004;83:712–717.
ment of dens invaginatus. J Endod 1977;3:360–362. 36. Rudich Z, Lerman SF, Gurevich B, Shahar G. Pain specialists’ evaluation of
14. Granhen H, Lindhal B, Omnell K. Dens invaginatus. I. A clinical roentgenologi- patient’s prognosis during the first visit predicts subsequent depression and
cal and genetical study of permanent upper lateral incisors. Odontol Revy the affective dimension of pain. Pain Med 2010;11:446–452.
1959;10:115–137. 37. Shanbhag S, Karnik P, Shirke P, Shanbhag V. Association between periapical
15. Kronfeld R. Dens in dente. J Dent Res 1934;14:49–66. lesions and maxillary sinus mucosal thickening: a retrospective cone-beam
computed tomographic study. J Endod 2013;39:853–857.
16. Rotstein I, Stabholz A, Heling I, Friedman S. Clinical considerations in the treat-
ment of dens invaginatus. Endod Dent Traumatol 1987;3:249–254. 38. Jiang M, You M, Wang H, Xu L. Characteristic features of the adenomatoid
odontogenic tumour on cone beam CT. Dentomaxillofac Radiol
17. Goncalves A, Goncalves M, Oliveira DP, Goncalves N. Dens invaginatus type III: 2014:20140016.
report of a case and 10-year radiographic follow-up. Int Endod J 2002;35:
873–879. 39. Tsesis I, Rosen E, Tamse A, Taschieri S, Kfir A. Diagnosis of vertical root fractures
in endodontically treated teeth based on clinical and radiographic indices: a
18. Kaufman AY, Kaffe I, Littner MM. Vitality preservation of an anomalous maxil- systematic review. J Endod 2010;36:1455–1458.
lary central incisor after endodontic therapy. Oral Surg Oral Med Oral Pathol
1984;57:668–672. 40. Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR. Detection of
vertical root fractures in endodontically treated teeth by a cone beam com-
19. Silberman A, Cohenca N, Simon JH. Anatomical redesign for the treatment of puted tomography scan. J Endod 2009;35:719–722.
dens invaginatus type III with open apexes: a literature review and case pre-
sentation. J Am Dent Assoc 2006;137:180–185. 41. Ozer SY. Detection of vertical root fractures of different thicknesses in end-
odontically enlarged teeth by cone beam computed tomography versus
20. Steffen H, Splieth C. Conventional treatment of dens invaginatus in maxillary digital radiography. J Endod 2010;36:1245–1249.
lateral incisor with sinus tract: one year follow-up. J Endod 2005;31:130–133.
42. Wang P, Yan XB, Lui DG, Zhang WL, Zhang Y, Ma XC. Detection of dental root
21. Kfir A, Telishevsky-Strauss Y, Leitner A, Metzger Z. The diagnosis and conserva- fractures by using cone-beam computed tomography. Dentomaxillofac
tive treatment of a complex type 3 dens invaginatus using cone beam com- Radiol 2011;40:290–298.
puted tomography (CBCT) and 3D plastic models. Int Endod J 2013;46:275–288.
43. Brady E, Mannocci F, Brown J, Wilson R, Patel S. A comparison of cone beam
22. Berkovitz BK, Holland GR, Muxham BJ. Tooth morphology. In: Berkovitz BK, computed tomography and periapical radiography for the detection of vertical
Holland GR, Muxham BJ (eds). Oral Anatomy, Histology and Embryology. root fractures in nonendodontically treated teeth. Int Endod J 2014;47:735–746.
London: Wolf, 1992:24–43.
44. Patel S, Brady E, Wilson R, Brown J, Mannocci F. The detection of vertical root
23. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular fractures in root filled teeth with periapical radiographs and CBCT scans. Int
first molar. Oral Surg Oral Med Oral Pathol 1971;32:778–784. Endod J 2013;46:1140–1152.
24. Gu L, Wei X, Ling J, Huang X. A microcomputed tomographic study of canal
isthmuses in the mesial root of mandibular first molars in a Chinese popula-
tion. J Endod 2009;35:353–356.

VOLUME 46 • NUMBER 6 • JUNE 2015 479

Q U I N T E S S E N C E I N T E R N AT I O N A L
Cohenca/Shemesh

45. Ferreira RI, Bahrami G, Isidor F, Wenzel A, Haiter-Neto F, Groppo FC. Detection 56. Lin LM, Gaengler P, Langeland K. Periradicular curettage. Int Endod J
of vertical root fractures by cone-beam computerized tomography in end- 1996;29:220–227.
odontically treated teeth with fiber-resin and titanium posts: an in vitro study. 57. Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry M, Patel A. Differential
Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:e49–e57. diagnosis of large periapical lesions using cone-beam computed tomography
46. Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR. Comparison of measurements and biopsy. J Endod 2006;32:833–837.
five cone beam computed tomography systems for the detection of vertical 58. Rosenberg PA, Frisbie J, Lee J, al. Evaluation of pathologists (histopathology)
root fractures. J Endod 2010;36:126–129. and radiologists (cone beam computed tomography) differentiating radicular
47. Kamburoglu K, Murat S, Yuksel SP, Cebeci AR, Horasan S. Detection of vertical cysts from granulomas. J Endod 2010;36:423–428.
root fracture using cone-beam computerized tomography: an in vitro assess- 59. Kocak-Berberoglu H, Cakarer S, Brkic A, Gurkan-Koseoglu B, Altug-Aydil B,
ment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e74–e81. Keskin C. Three-dimensional cone-beam computed tomography for diagno-
48. Jakobson SJ, Westphalen VP, Silva Neto UX, Fariniuk LF, Schroeder AG, Car- sis of keratocystic odontogenic tumours; evaluation of four cases. Med Oral
neiro E. The influence of metallic posts in the detection of vertical root frac- Patol Oral Cir Bucal 2012;17:e1000–e1005.
tures using different imaging examinations. Dentomaxillofac Radiol 60. Bornstein MM, Lauber R, Sendi P, von Arx T. Comparison of periapical radiog-
2014;43:20130287. raphy and limited cone-beam computed tomography in mandibular molars
49. Takeshita WM, Iwaki LC, da Silva MC, Sabio S, Albino PR. Comparison of peri- for analysis of anatomical landmarks before apical surgery. J Endod
apical radiography with cone beam computed tomography in the diagnosis 2011;37:151–157.
of vertical root fractures in teeth with metallic post. J Conserv Dent 61. Shekhar V, Shashikala K. Cone beam computed tomography evaluation of the
2014;17:225–229. diagnosis, treatment planning, and long-term followup of large periapical
50. Edlund M, Nair MK, Nair UP. Detection of vertical root fractures by using cone- lesions treated by endodontic surgery: two case reports. Case Rep Dent
beam computed tomography: a clinical study. J Endod 2011;37:768–772. 2013;2013:564392.
51. Metska ME, Aartman IH, Wesselink PR, Ozok AR. Detection of vertical root 62. Shemesh H, Cristescu RC, Wesselink PR, Wu MK. The use of cone-beam com-
fractures in vivo in endodontically treated teeth by cone-beam computed puted tomography and digital periapical radiographs to diagnose root perfor-
tomography scans. J Endod 2012;38:1344–1347. ations. J Endod 2011;37:513–516.
52. Corbella S, Del Fabbro M, Tamse A, Rosen E, Tsesis I, Taschieri S. Cone beam 63. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical
computed tomography for the diagnosis of vertical root fractures: a system- bone defects in human jaws using cone beam computed tomography and
atic review of the literature and meta-analysis. Oral Surg Oral Med Oral Pathol intraoral radiography. Int Endod J 2009;42:507–515.
Oral Radiol 2014;118:593–602. 64. Ahlowalia MS, Patel S, Anwar HM, et al. Accuracy of CBCT for volumetric
53. Barone C, Dao TT, Basrani BB, Wang N, Friedman S. Treatment outcome in measurement of simulated periapical lesions. Int Endod J 2013;46:538–546.
endodontics: the Toronto study – phases 3, 4, and 5: apical surgery. J Endod 65. Tanomaru-Filho M, Jorge EG, Guerreiro-Tanomaru JM, Reis JM, Spin-Neto R,
2010;36:28–35. Goncalves M. Two- and tridimensional analysis of periapical repair after end-
54. Lauber R, Bornstein MM, von Arx T. Cone beam computed tomography in odontic surgery. Clin Oral Investig 2015;19:17–25.
mandibular molars referred for apical surgery. Schweiz Monatsschr Zahnmed 66. Fineberg HV. Evaluation of computed tomography: achievement and chal-
2012;122:12–24. lenge. AJR Am J Roentgenol 1978;131:1–4.
55. Kurt SN, Ustun Y, Erdogan O, Evlice B, Yoldas O, Oztunc H. Outcomes of peri-
radicular surgery of maxillary first molars using a vestibular approach: a pro-
spective, clinical study with one year of follow-up. J Oral Maxillofac Surg
2014;72:1049–1061.

480 VOLUME 46 • NUMBER 6 • JUNE 2015