CBCT IN ENDODONTICS

DIVYA ANIL S
FINAL YEAR PART II
CONTENTS
• INTRODUCTION
• COMPARISON OF 2D AND 3D IMAGING
• CONE BEAM COMPUTED TOMOGRAPHY
• PRINCIPLES OF CBCT
• TYPES OF CBCT EQUIPMENT
• RADIATION DOSAGE
• ADVANTAGES
• LIMITATIONS
• ROLE OF IMAGING IN ENDODONTICS
• CLINICAL APPLICATIONS
• CONCLUSION
• REFERENCE
INTRODUCTION
• Cone Beam Computed Tomography (CBCT) is a diagnostic imaging
modality that provides high-quality, accurate three-dimensional
representations of the osseous elements of the maxillofacial skeleton
• A technique that enables three-dimensional reconstruction, but using a
conebeam to decrease the dose to the patient when compared to
conventional computerized tomography. (A Dictionary of Dentistry in
Medicine)
• CBCT systems are available that provide small field of view images at low
dose with sufficient spatial resolution for applications in endodontic
diagnosis, treatment guidance, and post treatment evaluation
COMPARISON OF 2D AND 3D IMAGING
• Intraoral radiography is based on the transmission,
attenuation, and recording of X-rays on an analog film or
digital receptor, and requires optimized geometric
configuration of the X-ray generator, tooth, and sensor to
provide an accurate projection of the tooth.
• The image produced is a two-dimensional (2D)
representation of a three-dimensional (3D)object
• complex dental anatomy and surrounding structures can
make interpretation of 2D "shadows“ difficult and can
contribute to non healing of endodontic cases
• cone-shaped beam and digital processing to reconstruct 3D
images
• differentiate between many types of structures and
airspaces including bone, teeth, airway, para nasal sinuses
sometimes soft tissue while avoiding diagnostic limitations
inherent in 2D images, including superimposition of
structures, non uniform magnification and distortion and no
depth information
• to visualize the patient as he or she truly exists and the
ability to view the anatomy from a variety of slice
thicknesses
CONE BEAM COMPUTED TOMOGRAPHY
• Cone Beam Computed Tomography [CBCT] is a three
dimensional imaging tool which has emerged as a
major diagnostic aid in dentistry
• Introduced in 1996
• The use of CBCT is profoundly increasing for
diagnosis and treatment planning in different
specialities of dentistry.
PRINCIPLES OF CBCT
• CBCT imaging is performed using a rotating platform
carrying an x ray source and detector
• A divergent cone shaped or pyramidal source of
radiation is directed through Region of Interest[ROI]
• X ray source and detector rotate around a rotation
center,fixed within centre of the ROI.
• During rotation, multiple sequential planar projection
images are obtained while the x ray source and
detector moves through an arc of 180 to 360 degree
• Single projection image from raw primary data which
is individually known as basis frame or raw image
• Usually several hundred 2D basic images from which
the image volume is calculated
• Complete series of image is called projection data.
TYPES OF CBCT EQUIPMENT
CBCT systems can be categorized according to the
• orientation of the patient
• scan volume irradiated
• clinical functionality
Patient Positioning
• Depending on the system employed, maxillofacial CBCT
can be performed with the patient in three possible
positions: Sitting
Standing
Supine
• Equipment that requires the patient to be supine has
a larger physical footprint and may not be readily
accessible for patients with physical disabilities.
• Standing units may not be able to be adjusted to a
height to accommodate wheelchair bound patients.
• Seated units are the most comfortable; however
fixed seats may not allow ready scanning of
physically disabled or wheelchair bound patients.
RADIATION DOSAGE
• For a significant comparison of radiation risk,
radiation exposures are converted to effective
dose,measured in sieverts(Sv).
• The Sv is a large unit; so in maxillofacial imaging ,
milli or micro sieverts are used.
ADVANTAGES OF CBCT
• Very Compact equipment
• Higher resolution resulting in sharper images and better diagnosis
• Produces a 3D rendition of a 2D image and provides geometrically
accurate images
• Increased specificity for caries, periodontal and periapical lesions when
compared to conventional CT and periapical radiographs.
• Small FOV hence possible to have images of only the area of interest.
• Fewer metal devices
• Less exposure time and lower radiation dose when compared to medical
CT.
• Patient comfort
• Good soft tissue rendition when compared to the traditional 2D imaging.
LIMITATIONS AND DRAWBACKS
• Despite the provision of the third dimension, the spatial
resolution of CBCT image is inferior to conventional
film-based or digital intraoral radiography
• CBCT has the problem of scattering and beam
hardening artifacts caused by high density structure
which diminishes the contrast and limits the imaging of
soft tissues. Therefore, CBCT is primarily indicated for
imaging hard tissues.
• CBCT has lengthy scan times (15-20 sec) and they need
the person to stay completely firmed
ROLE OF IMAGING IN ENDODONTICS
• Throughout the decades, imaging services have served a fundamental
role in all stages of the endodontic treatment process
Preoperative
• To analyze dental and alveolar hard tissue morphology
• Pathological alterations
• Morphology of tooth, including location and number of root canals, pulp
chamber size, calcifications, root structure directions and curvatures
• Iatrogenic defects
• Crown and root fractures
Intraoperative
• To determine proper working length of root canal system Tooth and bone
changes
Post operative
• To evaluate the root canal obturation and seal
• Tooth and periapical hard tissue changes after
treatment
• Planning for surgical considerations
CLINICAL APPLICATONS
Evaluation of root canal anatomy and complex morphology
• Knowledge of root canal anatomy and variations is essential for clinicians
to facilitate effective root canal treatment
• As a result, failure to distinguish and treat all canals can affect treatment
outcome.
• For example, the prevalence of a second mesiobuccal canal (MB2) in
maxillary first molars has been reported to be 69% to 93% depending on
the study method.
• This variability occurs in the buccolingual plane because of
superimposition of anatomic structures
• Conventional radiographs, at their best, can only reveal up to 55% of
these configuration. with increasing resolution of CBCT, the detection
rate enhanced from 60% to 93.3%
Assess the degree of curvatures associated with the
roots of teeth
• Teeth with anatomical and morphological anomalies
such as dens invaginatus and tooth fusion
• In a study that evaluated 608 permanent mandibular
second molars using CBCT a higher prevalence of "C"
shaped canals was noticed
• CBCT is an effective tool for the detection of
additional distolingual roots and C-shaped canals
Detection of Apical Periodontitis
• The most common pathologic conditions affecting the teeth are
the inflammatory lesions of the pulp and periapical areas.
• In this regard CBCT is significantly more accurate and sensitive
than conventional radiography in the identification of apical
periodontitis in humans, periapical bone destruction associated
with endodontic infection can be identified using CBCT before the
evidence of their existence becomes identifiable on conventional
radiographs.
• CBCT presented significantly more findings, such as expansion of
lesions into the maxillary sinus, sinus membrane thickening and
missed canals.
Assessment of the outcome of root canal treatment
• The most important area in which CBCT can be
applied in endodontics is in determining the
outcome of treatment.
• Earlier identification of periapical radiolucent
changes using CBCT may result in earlier diagnosis
and more effective management of periapical
disease
Pre-surgical planning
• Elimination of the superimposition of anatomic structures, such as
the zygomatic buttress, alveolar bone, maxillary sinus and other
roots, and early detection of the presence and dimensions of apical
lesions and changes in apical bone density.
• The axial, coronal and sagittal planes obtained with CBCT scans
also provide clinicians with a clear view of the anatomical
relationship between root apices and neighbouring structures,
such as the mandibular canal, mental foramen and maxillary sinus.
• The true size, location and extent of periapical lesions can be
appreciated with CBCT and the actual root with which the lesion is
associated can be confirmed.
Assessment of dental trauma
• Traumatic dental injuries present a challenge to clinicians worldwide.
• Horizontal root fractures usually affect maxillary central incisors and
are typically traumatic in origin, associated with accidents, sports
injuries or fights
• The absence of radiographic signs when the X-ray beam is not
parallel to the plane of the root fracture, tooth displacement and/or
alveolar bone fracture is a limitation of intra-oral Periapical
radiographs.
• Use of CBCT allows accurate diagnosis of the presence or absence, as
well as the exact location, extent and direction, of a horizontal
fracture line
Assessment of vertical root fracture, resorption or perforation
• Identifying the presence of vertical root fractures (VRF) is
often a challenge in endodontics.
• However, fine vertical cracks appear to not be revealed on
CBCT images at current CBCT resolutions
• Meister et al. suggested that VRF could only be detected
directly using Periapical radiographs if there is separation of
the root fragment and if the fracture traverses in the
direction of the X- ray beam. If the fracture is not in the plane
of the beam, the clinician is forced to make interpretations
based on periradicular bone loss
Dental Anomalies
• Dental anomalies include dens invaginatus (DI), short roots,
microdontia taurodontism, gemination, supernumerary
teeth,dentinogenesis imperfecta, agenesis, and malformations
resulting from trauma.
• The radiographic features of these anomalies have been studied
extensively and are well represented in the literature, showing
that deviations from normal anatomy can cause difficulties in
diagnosis and treatment.
• CBCT provides detailed information that can allow visualization of
the root morphology, resulting in better treatment planning and
postoperative assessments
CONCLUSION
This three-dimensional imaging technique overcomes the
limitations of conventional radiography and is a beneficial adjunct
to the endodontist's armamentarium. CBCT is an emerging
technology with the potential to revolutionize the diagnosis and
management of endodontic problems. An increasing number of
specific applications of CBCT in endodontics are being identified as
use of the technology becomes more wide-spread. Furthermore,
practitioners of CBCT must be adequately trained in CBCT radiology
as well as in the interpretation of the images obtained, because the
modality is completely different from conventional radiography. In
summary, a cautious and rational approach is advised when
considering the use of CBCT imaging in endodontics
REFERENCE
• TEXTBOOK OF ENDODONTICS- NISHA GARG
• ESSENTIALS OF ORAL AND MAXILLOFACIAL
RADIOLOGY- FRENY R KARJODKAR