CBCT IN ENDODONTICS

PRESENTED BY:
Dr.Saloni
PG Student
Dept. of cons and endo
CONTENTS:
 Introduction
 Limitations of periapical radiography

 CBCT-

1. Historical background
2. Classification of CBCT
3. Working principle
4. IMAGE ACQUISITION AND RECONSTRUCTION
5. Effective dose
6. Advantages
7. Disadvantages
8. DIFFERENCE BETWEEN CONE BEAM CT AND
CT
 Application of CBCT in Endodontics:
1. Assessment of apical periodontitis
 Periapical index based on CBCT
2. Presurgical Assessment
3. Assessment of Tooth Morphology and Complications
4. Assessment of Traumatic Injuries and Sequelae
5. Assessment of Vertical Root Fractures
6. Assessment of IRR
7. Assessment of the Outcome of Endodontic Treatment
8. Map-reading strategy to diagnose endodontic lesions
associated with root perforations
9. Guided endodontics
 CONCLUSION
 REFERENCE
INTRODUCTION :
 Diagnostic imaging - visualize dental anatomy in
areas that cannot be seen clinically.

 Radiography is essential to successful diagnosis of

odontogenic and nonodontogenic pathoses,
treatment of pulp chamber and canals of root of a
compromised tooth.
 Imaging serves at all stages in endodontics - preoperative
intraoperative and postoperative assessment.

 For years, periapical radiographs have been used as an

adjunct to help endodontists diagnose pathology and aid
the clinician in developing a treatment strategy.

 Recently a new imaging modality, cone-beam computed

tomography (CBCT), has been developed.introduced in
market and has been found to be useful in a number of
applications
 A recent technology initially developed for angiography
in 1982.

 Uses divergent or “cone“ shaped source of x rays

(conical or pyramidal) and a 2D area detector fixed on a
rotating gantry to acquire multiple sequential projection
images in one complex scan around area of interest.
LIMITATIONS OF CONVENTIONAL
RADIOGRAPHIC IMAGING
1. Compression of Three-Dimensional
Structures:
• Compresses 3D structures to 2D image.

• Radiograph - visualization of anatomy under

examination in MD plane.

• Anatomical complexities and diseases affecting the

dental hard tissues, such as resorption, operative
procedural errors cannot be accurately appreciated.
2. Geometric Distortion

 Minimum 5% magnification of object being radiographed

- final image, even when paralleling procedure is
executed perfectly .

 Unavoidable separation between image receptor and object

 Divergent nature of x-ray beam during imaging.

 Ultimate result  geometry of area being assessed is rarely
reproduced with complete accuracy using conventional
intraoral radiography.
3. ANATOMICAL NOISE

 Anatomy is projected over area of interest during conventional

radiographic imaging.
 Impair visualization of object under investigation and
complicate interpretation of radiograph.
 These anatomical interferences can vary in radiodensity

ANATOMICAL NOISE
 Anatomical noise caused by features of overlying
alveolar bone such as:

 Cortical plate
 Trabeculae and marrow spaces
 Complicating factors in the accurate detection of periapical
lesions and external root resorption.
CONE BEAM COMPUTED
TOMOGRAPHY
1. HISTORICAL BACKGROUND
 Cone beam computed tomography (CBCT) is a
contemporary, three-dimensional, diagnostic imaging
system designed specifically for use on maxillofacial
skeleton

 It has its origins in conventional medical CT.

 However, CBCT differs from latter in a number of

fundamental ways; differences which optimize its
suitability for dental imaging.

 First described by mozzo et al -1998

2. WORKING PRINCIPLE OF CBCT
3. IMAGE ACQUISITION AND
RECONSTRUCTION
 4 components for CBCT acquisition:
 X-ray generation

 Image detection system

 Image reconstruction

 Image display
 CBCT - X-ray source and detector, or sensor, mounted on a rotating gantry.

During imaging, a cone-shaped X-ray beam is emitted from the X-ray source and is directed through the area of interest in the patient’s maxillofacial skeleton.

Having passed through the area of interest, the beam is projected on to the X-ray detector, as both it and the X-ray source rotate synchronously 180°-360° around
the patient’s head, in a single sweep.

Scan time : 10-40

Projection images are then reconstructed, using sophisticated software, to produce a cylindrical or spherical volume of data, called the field of view (FOV).

Each projection image is comprised of up to and in excess of 216,124 (512 x 512) pixels.

The reconstructed, three-dimensional data set will comprise 5123 threedimensional pixels, or voxels .

Reconstructed CBCT images are then displayed simultaneously, in three orthogonal planes (axial, sagittal and coronal).
4.PRINCIPLES OF CBCT
FIELD OF VIEW/SCAN VOLUME

 Amount of area to be exposed in a single scan.

 Depends on:
 Detector size
 Geometry of beam projection
 Collimation of beam

 Shape – cylinder or Spherical

 Can be selected based on individual requirements

VOXEL
 Spatial resolution is determined by individual volume
elements called voxels.

 These are cubic in nature equal in all dimensions

 Principle determinant of voxel size is pixel size of the

detector.

 Detectors with smaller pixel size capture fewer xray

photons per voxel and result in more noise.

 To balance it out a good scanner has higher dosage of

radiation
GRAYSCALE
 The ability of a cbct scan to display differences in attenuation.

 This parameter is called bit depth of the system and determines the
number of shades of grey available to display the attenuation.

 All current CBCT machines have 12 bit detectors and are capable of
identifying 4096 shades of gray .
EXPOSURE SETTINGS
 ALARA principle

 Can controlled either automatic or manual adjustment of

kVp or Ma

 Scout exposure- high energy x rays can be avoided by

taking an initial scout exposure, amount of electrons
generated by the patient is registered on the sensor and
the exposure settings are adjusted.
SCAN TIME
 Average time for one cbct scan may : 7-30 seconds.

 This is the scan time including the initial scout

image scan

 It also varies if half a rotation or a full circle

rotation is used.

 Standard scan- 3-4 seconds, lower resolution ,

reduced scan time.
RESOLUTION
 Ability of an image to differentiate between two closely
placed objects.

 Two types:
 Spatialresolution
 Contrast resolution

 Spatial resolution – the ability to visualize the difference

between two objects of different radio density

 Contrast resolution – ability to differentiate two objects of

the same color type.
5.CLASSIFICATION OF CBCT

FOV/SCAN VOLUME PATIENT POSITION

Small volume/
focused/small HIGH VOLUME :
field/limited field/limited SINGLE ARCH CBCT – SUPINE SITTING STANDING
volume -maximum scan 5-7CM
volume height of 5 cm
6.EFFECTIVE DOSE OF CBCT
 Radiation dose dependent on:
 EXPOSURE PARAMETERS:
 Nature of X-ray beam - Continuous /pulsatile
 Degree of rotation of X-ray source and detector
 Size of FOV

 Amount and type of beam filtration

 kV, mA and voxel size settings on most systems.

 Effective dose is measured in Sieverts (Sv) and is often
expressed in micro Sieverts (Sv), as the figures involved are
so low .

 Small volume CBCT scanners are well suited for use in

Endodontics as the area of interest can easily be captured by
their smaller FOV.

 Effective radiation dosage

• FOV>15 cm – 52 to 1073 μSv
• FOV 10 to 15cm – 61 to 603 μSv
• FOV of < 10 cm - 18 to 333 μSv
• Multislice CT - 426-1600 μSv
• Panaromic – 6-50 μSv
• Cephalogram - 2 -10 μSv
• IOPA - 2-8 μSv
7.ADVANTAGES OF CBCT
CBCT overcomes limitations of conventional radiography:

 Production of 3D images - anatomy, and its spatial relationship to

tissue destruction caused by pathosis under examination.

 Slices of volumetric data can be chosen by clinician and viewed

in all the orthogonal planes and in non-orthogonal planes.
Anatomical noise  easily eliminated .
 CBCT voxels - isotropic images produced are
geometrically accurate and image measurements, in any
plane, are free from distortion .

 Reduced patient exposure

 Superior image quality with respect to dental hard tissue

and bone assessment.

 CBCT X-ray beam – pulsatile  Patient exposed to

radiation for only a small portion of overall scan time.
 X-ray source - collimated only area of interest is
radiated, producing a specific volume of data (FOV)
appropriate and relevant to the patient’s needs.

 Software CBCT data reconstruction can be run on

personal computers chairside diagnostic and treatment
planning tool.

 Multiple slices can be scrolled through in real time

producing dynamic images.

 Cursor driven measurements allow dimensional

assessments to be made in real-time.
 Basic image manipulations are possible.
 Window levels can be adjusted
 Specific areas can be magnified
 Annotations can be added
 Surface rendering software is also available

 Scan times - short and comparable with

panoramic radiography Patient movement
during scan is less.

 CBCT hardware is much smaller and less

expensive than CT machines.
 8.LIMITATIONS OF CBCT

I. Radiographic artefacts related to X-ray beam.

ACQUISITION ARTIFACTS- BEAM HARDENING
CBCT X-ray beam encounters an object of very high density(enamel or metallic restorations)

Lower energy photons in beam are absorbed by structure in preference to higher energy
photons

Mean energy of X-ray beam increases.

‘Beam hardening’

Produces two types of artefact:

Distortion
Distortion of
of metallic structures‘cupping artefact’
metallic structures‘
Appearance of
Appearance of streaks
streaks and
and dark
dark bands
bands between
between two
two dense
dense structures.
structures.
In clinical
practice it is
advisable to
reduce field size ,
modify patient
position ,
separate dental
arches to avoid
beam hardening

Remove metallic
objects – to avoid
beam hardening
PATIENT RELATED ARTIFACT
 Patient motion – unsharpness in image reconstruction
 Minimize by restraining head

Motion blur double cortices

ALAISING ARTIFACT / MOIRE PATTERN

 Alaising artifacts appear as

slightly wavy lines that diverge
outwards toward periphery of a
cone beam image.
 Cause – By undersampling of
structures.

 Related to the size of the dexels

within the detector.

 Dexels - measure the energy of

the incident x-ray or light photons
IMAGE NOISE
 Random variation in number of x-ray photons
in the beam as it exits an object and strikes
the image detector produces a grainy or
mottle appearance within the image.
Increase in voxel size reduces grainy app but spatial resolution
and detection of small object reduced
SCANNER RELATED ARTIFACTS
 Circular / ring steaks
 Result from imperfections in
scanner detection
 Cause – repetitive reading at
each angular position of
detector.
CONE BEAM RELATED ARTIFACTS
 Beam projection geometry and image
reconstruction causes these artifacts:
1. PARTIAL VOLUME AVERAGING : when
selected voxel size of the scan is larger than the
size of object being imaged.

2. UNDERSAMPLING: occur when too few basic

projections are provided for image reconstruction.
 Reduced data sample leads to sharp edges, noisier images ,
Fine striations in the image .

Pictorial plot of effect of no. of basic projection images and size

of FOV on i,mage quality
CONE BEAM EFFECT
 Potential source of artifacts
 Seen in peripheral portions of scan volume

 Because of divergence of x ray beam as it rotates around

the patient in horizontal plane, structures at top and
bottom of the image field only be exposed when x ray
beam is in opposite side of patient.
 Results – image distortion, streaking artifacts , greater
peripheral noise .

 To minimize – Positioning the Region of interest in

horizontal plane of the x ray beam.
 Peripheral area – less
denser
 More image noise
CBCT VS CT
APPLICATIONS OF CBCT IN
ENDODONTIC PRACTICE
 Use of CBCT in endodontics should be limited to
assessment and treatment of complex endodontic
conditions such as:
a) Identification of root canal system anomalies and
determination of root curvature.

b) Diagnosis of dental periapical pathosis in patients who

present with contradictory or nonspecific clinical signs
and symptoms, who have poorly localized symptoms
associated with an untreated or previously endodontically
treated tooth with no evidence of pathosis identified by
conventional imaging

c) Diagnosis of pathosis of non -endodontic origin in order

to determine extent of lesion and its effect on surrounding
structures.
c) Intra- or postoperative assessment of endodontic treatment
complications, such as overextended root canal obturation
material, separated endodontic instruments, calcified canal
identification and localization of perforations.

d) Diagnosis and management of dentoalveolar trauma,

especially root fractures, luxation and/or displacement of teeth,
and alveolar fractures.

e) Localization and differentiation of external from internal root

resorption or invasive cervical resorption from other
conditions

f) Presurgical case planning to determine the exact location of

root apex/apices and to evaluate the proximity of adjacent
anatomical structures.
1.DETECTION OF APICAL
PERIODONTITIS
 CBCT enables the detection of radiolucent findings before they are
visualized on conventional radiographs.

Periapical radiograph of 46 Sagital CBCT slice of 46. Note extensive

periapical radiolucency
 Periapical lesions in cancellous bone cannot be detected
radiographically.

 CBCT, however, can reveal bone defects of the cancellous

bone and cortical bone separately.

 The prevalence of apical periodontitis was found to be

significantly higher when using CBCT, in comparison with
periapical radiographs.
 Detection of apical periodontitis was considerably higher
with CBCT than with periapical radiography CBCT
more sensitive diagnostic method to identify apical
periodontitis.- Estrella C etal ,JOE 2008
Panoramic and periapical radiographs
show normal periapical area of the upper
right incisor. Apical periododntitis can
be seen in the CBCT.
PERIAPICAL INDEX BASED ON CBCT
 New periapical index CBCT PAI (Estrela et al., 2008) was proposed based on CBCT
for identification of apical periodontitis.
 The CBCT-PAI was determined by the largest lesion extension.
Schematic representations of incisors CBCTPAI.
2. PRESURGICAL ASSESSMENT
 Three-dimensional imaging allows the anatomical relationship of
the root apices to important anatomical structures, such as the
inferior dental canal, mental foramen and maxillary sinus, to be
clearly identified in any plane the clinician wishes to view.

 CBCT may play an important role in planning for periapical

microsurgery on the palatal roots of maxillary first molars.
 The distance between the cortical plate and the palatal root apex
could be measured, and the presence or absence of the maxillary
sinus between the roots could be assessed.
 By selecting relevant views and slices of data, the thickness of the
cortical plate, the cancellous bone pattern, fenestrations, as well as the
inclination of the roots of teeth planned for surgery, can be accurately
determined preoperatively.
• Periapical radiograph of a mandibular left first molar tooth. The tooth has remained
symptomatic and there is radiographic evidence of persistent apical periodontitis (solid
white arrow) one year after non-surgical root canal treatment.
• (b,c) Coronal (b) and sagittal (c) CBCT slices through the same tooth.
• The spatial relationship of the mesial root-end (solid white arrows) to the buccal cortical
plate (dashed white arrow) and the inferior dental canal (black arrows) can be assessed and
measured accurately prior to apical root-end surgery.
3.ASSESSMENT OF TOOTH
MORPHOLOGY AND COMPLICATIONS
 Root morphology and bony topography visualized in 3-D

 Unidentified and untreated root canals - identified using axial

slices, which may not be readily identifiable with periapical
radiographs.

 CBCT images accurately identified the presence or absence of

the MB2 canal in 78.95% of samples.

 CBCT images have clearly demonstrated the presence of

untreated or missed canals intraoperatively or in root-filled
teeth, as well as complications (i.e., perforations)
Axial CBCT slice of maxillary
left quadrant. Missed MB2
canal of tooth #26
Periapical radiograph of tooth
Axial CBCT slice of same tooth revealing a
#36 with separated instrument in
strip perforation of distal root at a level
distal root.
coronal to separated
instrument.
Periapical radiograph of tooth #35.
There is an associated radiolucency at Coronal CBCT slice - missed buccal canal and
the apex of this root-filled an associated apical radiolucency.
4. ASSESSMENT OF TRAUMATIC INJURIES
AND SEQUELAE
 Horizontal root fractures, resorptive defects (internal,
external and invasive cervical) and alveolar fractures are
readily observed and differentiated on CBCT images
whereas their diagnoses on periapical radiographs are
often quite difficult
5.ASSESSMENT OF ROOT FRACTURES:
 CBCT - significantly better than conventional
radiographs in the diagnosis of vertical root fractures.

Sagital CBCT slice of tooth revealing an isolated osseous radiolucent defect along the
mid-distal aspect suggestive of a root fracture.
6. DIAGNOSIS, ASSESSMENT AND MANAGEMENT
OF ROOT RESORPTION

 The sensitivity of conventional radiography is

significantly poorer than CBCT in the detection of ERR
in its early stages.
 Accurate assessment is essential as the pathogenesis of
external and internal root resorption is different and
treatment protocols vary.
 early detection with periapical radiography is not
considered reliable because of the difficulty in identifying
lesions on the buccal or lingual/palatal surfaces. In
contrast, CBCT makes it possible to examine the region
of interest in any plane, determine accurate
measurements
CBCT
images of the ( b ) cross-
sectional reformation,
( c ) axial reformation,
and ( d ) sagittal
reformation
show features consistent
with external
inflammatory resorption
of the palatal root
( arrows ) and a
periradicular
periodontitis, which could
not be localized in the
periapical
radiograph.
( a ) Periapical radiograph of the
maxillary right central incisor
reveals an approximately 3–4 mm
long, long, 1 mm diameter, oval,
well-defi ned area of low density
centered mesiodistally, with calcifi
cation
of the remaining pulp space
( arrow ); features consistent with
internal resorption and canal
calcifi cation. CBCT images of the
( b ) sagittal reformation, ( c )
axial reformation, and ( d )
crosssectional
reformation show the location of the
resorptive lesion ( arrows ) and its
relationship to the
calcifi ed canal. The resorptive
lesion was non-perforating,
positioned facially, and separate
from
the pulp space.
7. ASSESSMENT OF THE OUTCOME OF
ENDODONTIC TREATMENT

 For a more accurate assessment of the outcome of root canal

treatment using CBCT, preoperative scans and post-treatment
review scans should be compared.
8. MAP-READING STRATEGY TO DIAGNOSE
 Bueno et al. (2011) suggested a mapreading strategy to
ENDODONTIC LESIONS ASSOCIATED WITH
diagnose
ROOT root perforations near metallic intracanal posts by
PERFORATIONS
using CBCT.

 One strategy to minimize metallic artifact in root perforation

associated with intracanal posts is to obtain sequential axial
slices of each root, with an image navigation protocol from
coronal to apical (or from apical to coronal), with axial
slices of 0.2 mm/0.2 mm.

 This map reading provides valuable information showing

dynamic visualization toward the point of communication
between the root canals and the periodontal space, associated
with radiolucent areas, suggesting root perforation
Navigation in axial slices of 0.2 mm/0.2 mm involving the coronal to apical direction (and also in apical
to coronal direction) provided important information regarding better
visualization and localization, suggesting diagnosis of root perforation associated with lateral
radiolucency.
GUIDED ENDODONTICS:
 Recently, the concept of guided endodontics has been
reported, in which computer-designed guides are used
for access cavity preparation (van der Meer et al. 2016,
Krastl et al. 2016) and endodontic surgery (Strbac et al.
2017), in order to achieve predictable and safe results
(Anderson et al. 2018).
 Pre-clinical studies have reported a high accuracy of the
procedure when comparing the drilled path to the
planned treatment without being influenced by the
operator’s experience.
 Additionally, the use of a guide for treatment may
reduce chair time
 This novel concept could help clinicians during
treatments, it may avoid unnecessary removal of tissue,
avoiding complications and therefore, improving the
prognosis of treatment (Zehnder et al. 2016, Connert et
al. 2018).
 Workflow for guided endodontics.
A CBCT from the patient is acquired (a) as well as a digital
intraoral impression directly (b.1) or indirectly .
The information from both sources is combined and
registered in a digital planning software
(c). Then, a treatment guide is designed
(d) and fabricated
(e). Finally, the guide is either used during guided access
cavity preparation or apical surgery (f.2: image adapted
from Ahn et al. 2018).
CONCLUSION:
 The additional information provided by CBCT may increase and/or
improve diagnostic accuracy and confidence in decision-making as
well as have an impact of treatment planning.
 However, CBCT imaging comes at the expense of increased
radiation dose; therefore, CBCT should only be reserved for cases
where there is potential benefit from a three-dimensional
assessment.
 It is essential that patient radiation exposure is kept as low as
reasonably practicable . The benefits of a CBCT investigation must
outweigh any potential risks.
 Therefore, each scan must be optimized to reduce patient exposure
by adjusting the CBCT settings, thus allowing each examination to
be personalized to the individual patient and the diagnostic needs,
rather than just using manufacturer’s default settings.
REFERENCE
 Endodontic Radiology, Second Edition- Bettina Basrani
 EndodoNtics: Colleagues for Excellence; American
Association of Endodontists
 Oral Radiology : Principles and Interpretation. 5th ed.
Stuart C. White & Michael J. Pharoah.
 Dental Applications of Computerized Tomography.
Stephen L . G. Rothman
 Fundamentals of Special Radiographic Procedures.5th
ed. Albert M. Snopek.