Applications of Cone-Beam Computed Tomography in Dental Practice: A Literature Review

Dental News Volume XVIII, Number II, June, 2011

by Dr. Mohammed A. Alshehri, Dr. Hadi Alamri & Dr. Mazen Alshalhoob, Saudi Arabia

Abstract

This article presents a review of the clinical applications of cone-beam computed tomography (CBCT) in different dental disciplines. A literature search was conducted via PubMed for studies on dental applications of CBCT published between 1998 and 2010. The search revealed a total of 540 results, of which 130 articles were clinically relevant and were analyzed in detail. CBCT is used in different dental disciplines for numerous clinical applications. The results of this systematic review show the different applications of CBCT imaging in dental practice, which are summarized and categorized under eight different dental disciplines.

Introduction

Two-dimensional (2D) imaging modalities have been used in dentistry since the first intraoral radiograph was obtained in 1896. Since then, significant advances have been made in dental imaging techniques, including the introduction of panoramic imaging techniques and tomography. Advances in digital imaging techniques have led to lower radiation doses and faster processing times without changing the imaging geometry of these intraoral and panoramic technologies.

Cone-beam computed tomography (CBCT) is a new medical imaging technique that generates three-dimensional (3D) data at lower cost and lower absorbed doses than conventional computed tomography (CT). The CBCT imaging technique is based on a cone-shaped X-ray beam that is centered on a 2D detector, and the beam performs one rotation around the object, producing a series of 2D images. The images are reconstructed in a 3D data set using a modification of the original cone-beam algorithm developed by Feldkamp et al. in 1984²⁷. CBCT images from the craniofacial region are often acquired at a higher resolution than conventional CT. In addition, these systems are more compact than conventional CT systems, which make them more practical for use in dental offices⁴⁸.

The application of CBCT imaging in different dental disciplines can guide diagnosis, treatment and follow-up.

This article presents a systematic review of clinical applications of CBCT in dental practice.

Materials and methods

A literature search was conducted via PubMed for CBCT imaging applications in dentistry published between January 1, 1998 and July 15, 2010 using the keywords “Cone-beam computerized tomography in dentistry”. The search revealed a total of 540 articles, which were all screened in detail. Of these articles, 410 were excluded because they were not relevant to the subject. The systematic review consisted of 130 clinically relevant articles that were analyzed further and categorized according to the discipline of application.

Results

The search revealed 36 articles (27.7%) related to applications in oral and maxillofacial surgery (OMFS), 33 articles (25.4%) related to endodontic clinical applications, 22 articles (16.9%) related to clinical applications in implant dentistry, 15 articles (11.5%) related to orthodontic clinical applications, 10 articles (7.7%) about clinical applications in general dentistry, 8 articles (6.2%) about the temporomandibular joint (TMJ), 5 articles (3.8%) related to applications in periodontology, and 1 article (0.8%) about CBCT applications in forensic dentistry.

Table 1. Summary of CBCT application-related articles according to dental specialty

Review

Applications in oral and maxillofacial surgery

CBCT in OMFS has been used to investigate the exact location of jaw pathology in 3D images^{3, 14, 29, 65, 81, 93, 90, 102, 126}, to assess impacted teeth (Fig. 1), to assess supernumerary teeth and their relation to vital structures^{18, 61, 62, 65, 66, 69, 80, 90, 113, 115, 123}, to evaluate changes in the cortical and trabecular bone related to bisphosphonate-associated osteonecrosis of the jaws^{12, 29, 57}, and to assess bone grafts³⁴. CBCT has also been used to investigate paranasal sinuses^{6, 65} and to assess obstructive sleep apnea^{78, 88}.

Fig 1. Impacted teeth in close proximity to vital structures, requiring evaluation using CBCT.

Because CBCT images are collected as a combination of several 2D slices, the technique is superior in overcoming superimpositions and calculating surface distances^{9, 10}. This advantage has made CBCT the technique of choice for the investigation of mid-facial fractures^{8, 41}, orbital fracture assessment and management¹²⁸, and in inter-operative visualization of the facial bones after fracture^{39, 40}. Furthermore, because CBCT is not a magnetic resonance technique, it is the best option for intraoperative navigation during procedures involving gun-shot wounds ^{72, 96}.

CBCT is largely used in planning orthognathic and facial orthomorphic surgeries, which require detailed visualization of the interocclusal relationship to augment the 3D virtual skull model with a detailed representation of the dental surface. With the aid of advanced software, CBCT facilitates the visualization of soft tissue to allow for control of the post-treatment aesthetics^{7, 111, 112} and permits the evaluation of lip and palate bony depressions in cases of cleft palate^{56, 73, 125}.

The ability of CBCT to detect salivary-gland defects is also under investigation¹⁰⁸. In addition, one article has reported a tooth autotransplant case where CBCT demonstrated high accuracy, and the information provided allowed the rapid completion of the transplant operation⁴⁵.

Clinical application in endodontics

CBCT is a useful tool in diagnosing apical lesions (Fig. 2a, 2b) ^{13, 17, 19, 20, 23, 25, 31, 64, 83, 84, 92, 115, 120}. A few research studies have shown that contrast-enhanced CBCT images can be used to differentiate between apical granulomas and apical cysts by measuring the lesion density (Fig. 3a, 3b) ^{23, 92, 120, 106}. Another article describes the use of CBCT as a tool to categorize the origin of the lesion as endodontic or non-endodontic¹⁷.

Fig 2a. A periapical lesion in a periapical radiograph (courtesy of Dr. Fredrek Barnett).

Fig 2b. The same periodical lesion in a CBCT image (courtesy of Dr. Fredrek Barnett).

Fig 3a. An apical cyst in an OPG radiograph.

Fig 3b. The same apical cyst in a CBCT image.

The superiority of CBCT in detecting fractured roots compared to 2D radiographs has been demonstrated by several clinical case reports focused on detecting vertical root fractures^{17, 77, 89, 92, 106, 115, 120}. CBCT is considered superior to periapical radiographs in the detection of fractures in buccolingual or mesiodistal directions^{35, 36}, in the measurement of depth in dentin¹³³ and in the detection of horizontal root fractures^{17, 92, 115}.

CBCT is able to detect lesions in cases of inflammatory root resorption, whereas conventional 2D x-rays cannot detect them in early stages^{24, 115}. In other cases such as external root resorption ^{17, 60, 115, 120}, external cervical resorption ^{17, 84, 91}, and internal resorption ^{17, 84, 115, 120}, CBCT cannot only detect the presence of resorption but also its extent.

CBCT can be used to determine root morphology; to measure the number of roots, canals, and accessory canals; and to establish their working lengths and angulations^{6, 17, 70, 77, 92, 98, 115, 119, 120}. CBCT also provides accuracy in the assessment of root canal fillings^{19, 31, 77, 120}, in the detection of pulpal extensions in talon cusps¹⁰⁷ and in the detection of the position of fractured instruments¹¹⁸.

CBCT is a reliable tool for the presurgical assessment of the proximity of the tooth to adjacent vital structures, the size and extent of a lesion, and the anatomy and morphology of roots through very accurate measurements^{17, 20, 25, 46, 54, 77, 84, 92, 97, 106, 115, 118, 120}. In emergency cases requiring tooth assessment after trauma, CBCT applications can aid in reaching a proper diagnosis to determine the most suitable treatment approach^{15, 16, 17, 92}. Due to its reliability and accuracy, CBCT has recently been used to evaluate canal preparation in different instrumentation techniques^{74, 76}.

Applications in implant dentistry

The increasing demand for dental implants to replace missing teeth has necessitated a technique capable of obtaining highly accurate measurements to avoid any damage to vital structures. Previously, such measurements were obtained through conventional CT; however, the ability of CBCT to provide greater accuracy in measurements at lower radiation doses has made it the preferred option in implant dentistry (Fig. 4a, 4b)^{21, 28, 32, 37, 46, 47, 48, 63, 65, 67, 90, 101, 103, 104 114, 116, 121, 126}. Furthermore, the presence of new software to construct surgical guides has further reduced the possibility of structural damage^{2, 21, 30, 85, 86, 101}. Another article describes the interoperative use of CBCT in two cases to guide the insertion of the implant after microsurgical bone transfer³⁸.

Fig 4a. An OPG radiograph for a full-mouth rehabilitation case. The data that was obtained from this image was limited.

CBCT can be used to measure bone quality^{4, 37, 46, 47, 78, 90, 109, 110} and quantity^{37, 103, 109, 116}, which has led to a reduction in implant failure because the reliable information provided by CBCT has led to improvements in case selection. CBCT is also used to assess the success of bone grafts and post-treatment evaluations (Fig. 5a to 5d)^{90, 116}.

Fig 5a. A clinical image of multiple implants placed 5 years ago.

Fig 5b. A periapical radiograph for implants replacing teeth 8 and 9. The data that was collected from this image was limited.

Fig 5c. A CBCT image clearly showing the amount of bone loss.

Fig 5d. A CBCT image showing evidence of total buccal plate destruction.

Applications in orthodontics

The introduction of new software in orthodontic assessment has enabled the use of CBCT images in cephalometric analysis^{26, 46, 59, 65, 101} and has led to CBCT becoming the tool of choice for assessing facial growth, age, airway function^{1, 55, 105}, and disturbances in tooth eruption⁷⁵.

CBCT is a reliable tool in assessing the proximity of the tooth to vital structures that may interfere with orthodontic treatment^{22, 94}. In cases that require the placement of tiny screw implants as temporary anchors, CBCT acts as a useful visual guiding technique for safe insertion of these anchors^{52, 53, 95} as well as to assess the bone density before, during and after treatment (Fig. 6)^{33, 99}.

CBCT incorporates multiple different views of an object in one scan (e.g., frontal, right lateral, left lateral, 45-degree, and submental views), which is an additional advantage of the technique^{58, 124}. CBCT is therefore considered a more accurate option for the clinician because the images are self-corrected for magnification, producing orthogonal images with a 1:1 ratio⁵.

Fig 6. A CBCT image to assess bone density during treatment.

Applications in TMJ imaging

One of the major advantages of CBCT is its ability to define the true position of the condyle in the fossa, which often reveals the possibility of dislocation of the disk in the joint ^{90, 117, 120} and the extent of translation of the condyle in the fossa¹¹⁷. Due to its accuracy, CBCT facilitates easy measurement of the roof of the glenoid fossa^{51, 68} and provides the ability to visualize soft tissue around the TMJ⁴⁴, which may reduce the requirement for the use of MRI in these cases.

Due to these advantages, CBCT has become the imaging device of choice in cases of trauma, pain and dysfunction, and fibro-osseous ankylosis^{43, 82, 100, 114}, as well as in the detection of condylar cortical erosion and cysts⁴⁶. The use of 3D features facilitates the safe application of the image-guided puncture technique, which is a treatment modality for TMJ disk adhesion⁴².

Periodontics applications

The high measurement accuracy of CBCT with minimal margins of error allows its use in obtaining a detailed morphologic description of the bone^{120, 122}, with measurement accuracy equal to that of direct measurement with a periodontal probe^{71, 120}. CBCT also aids in assessing furcation involvement^{68, 115,120}.

CBCT can be used in the detection of buccal and lingual defects^{49, 120} where conventional 2D radiography shows limitations. CBCT allows accurate measurement of intrabony defects^{11, 79} as well the ability to assess dehiscence, fenestration defects and periodontal cysts^{50, 120}. CBCT has also proved its superiority in evaluating the outcome of regenerative periodontal therapy⁴⁹.

Operative dentistry applications

Based on the data in the available literature, the use of CBCT in detecting occlusal caries is not yet justified because CBCT delivers a higher radiation dose to the patient compared to conventional 2D radiographs with no additional benefit. However, CBCT has proved to be useful in assessing the depth of proximal caries¹¹⁵.

Table 2 shows examples of typical radiation doses received from various dental radiological procedures in operative dentistry.

Table 2. Typical doses from various dental radiological procedures

Forensic applications

Dental age estimation is considered an important factor in the field of forensic science, and this estimation can be performed non-invasively using CBCT; an estimate of a subject’s age can then be derived from the subject’s pulp/tooth ratio¹²⁷.

Discussion

CBCT scanners represent a significant advancement in dental and maxillofacial imaging. Since their introduction for dental use in the late 1990s ¹²⁹, there has been an increased interest in these devices. The number of CBCT-related articles published per year has increased tremendously over the last few years. We have performed a systematic review of the literature related to CBCT imaging applications in dental practice and summarized the applications of this new imaging technique in different dental specialties.

CBCT was used as a keyword in this systematic review. Although other keywords and terminology were entered into the PubMed search engine (e.g., cone beam volumetric scanning, true volumetric computed tomography, dental CT, dental 3D-CT, and cone beam volumetric imaging), they did not result in additional relevant articles¹³⁰.

The clinical applications of CBCT imaging in dentistry are constantly increasing. The results of this systematic review showed that of the 540 articles published in the last 12 years, 130 were clinically relevant. The most common clinical applications of CBCT were in OMFS, implant dentistry, and endodontics. CBCT has shown limited use in operative dentistry because of the high radiation dose compared to conventional 2D radiography without any additional benefit.

The dental literature on CBCT is promising and indicates that more research is required to explore the benefits of CBCT in forensic dentistry. Although no literature was found on prosthodontic applications of CBCT, the improved standard of care seen in prosthodontic treatment can be attributed to applications of CBCT found in other dental specialties and related to prosthodontic, such as bone grafting, soft tissue grafting, prosthetic-driven implant placement, maxillofacial prosthodontics and Temporomandibular joint disorders. CBCT images are important in special cases that require the assessment of restorability of multiple teeth (Fig. 7a to 7e).

Fig 7a. Multiple endodontically treated teeth in a patient with a history of periodical surgery.

Fig 7b. A periodical image showing a compromised crown-to-root ratio.

Fig 7c. A CBCT image showing the absence of the buccal plate and a compromised palatal plate; this image indicates the teeth to be extracted and the grafting site before implant placement.

Fig 7d. A photograph showing the location of bone grafting. The least traumatic extractions were performed for teeth 7, 8, 9 and 10.

Fig 7e. A photograph shows the in-progress healing of the grafted sites intended for the future placement of implants.

The newest CBCT systems show higher resolution and lower exposure than previous systems, and the new systems are less expensive and more specific for dental use than their predecessors. The flat-panel detectors are less prone to beam hardening artifacts. CBCT also shows disadvantages such as susceptibility to motion artifacts, low contrast resolution, and limited internal soft-tissue visualization capability. Furthermore, due to the distortion of Hounsfield units, CBCT cannot be used for the estimation of bone density.

As far as the radiation dose of CBCT imaging is concerned, it is crucial that a radiation dose as low as reasonably achievable (alara) is respected. Although CBCT imaging will certainly improve patient care, dentists must possess the anatomical knowledge and the experience to interpret the scanned data accurately. Dentists must evaluate whether these imaging modalities add to their diagnostic knowledge and raise the standard of dental care or simply place the patient at a higher risk. Such evaluation requires continuous training, education for dentists and thorough research.

One of the most clinically useful aspects of CBCT imaging is the availability of highly sophisticated software that allows the large volumes of acquired data to be broken down, processed and reconstructed¹³¹. This ability makes data interpretation much more user-friendly, particularly if competent technical and educational training is provided to the dentists and technicians.

The increasing popularity of CBCT has resulted in the manufacture of a large number of CBCT units, numerous presentations at conferences and a significant increase in published articles. These factors have led to an uncontrolled and non-evidence-based reporting of radiation dose values that can be attributed to the limited technical knowledge of medical imaging devices among new users. To counter this uncontrolled exchange, the European Academy of Dental and Maxillofacial Radiology has developed guidelines outlining the basic principles for the use of CBCT in dental applications¹³²; these guidelines are shown in Table 3.

Table 3. Basic principles on the use of CBCT in dental applications (from eadmft)

Conclusions

The majority of CBCT applications in the practice of dentistry are found in the specialties of OMFS, endodontics, implant dentistry, and orthodontics. CBCT examinations must not be performed unless they are necessary and unless the benefits clearly outweigh the risks. The images acquired using CBCT must undergo a thorough clinical evaluation of the entire image dataset (i.e., a radiological report should be completed) to maximize the clinical data obtained from these images.

Future research should focus on obtaining accurate data regarding the radiation doses of CBCT systems. These systems have a small detector size, and the field of view and scanned volume are somewhat limited. Due to these factors, ideal CBCT systems for orthodontic and orthognathic surgery are not yet available. CBCT applications in forensic dentistry and prosthodontics require further investigation.

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