Restor Dent Endod.  2024 Feb;49(1):e1. 10.5395/rde.2024.49.e1.

Cone-beam computed tomography in endodontics: from the specific technical considerations of acquisition parameters and interpretation to advanced clinical applications

• Ríos-Osorio N
• Quijano-Guauque S
• Briñez-Rodríguez S
• Velasco-Flechas G
• Muñoz-Solís A
• Chávez C
• Fernandez-Grisales R

• KMID: 2554129
• DOI: http://doi.org/10.5395/rde.2024.49.e1

Abstract

The implementation of imaging methods that enable sensitive and specific observation of anatomical structures has been a constant in the evolution of endodontic therapy. Conebeam computed tomography (CBCT) enables 3-dimensional (3D) spatial anatomical navigation in the 3 volumetric planes (sagittal, coronal and axial) which translates into great accuracy for the identification of endodontic pathologies/conditions. CBCT interpretation consists of 2 main components: (i) the generation of specific tasks of the image and (ii) the subsequent interpretation report. A systematic and reproducible method to review CBCT scans can improve the accuracy of the interpretation process, translating into greater precision in terms of diagnosis and planning of endodontic clinical procedures. MEDLINE (PubMed), Web of Science, Google Scholar, Embase and Scopus were searched from inception to March 2023. This narrative review addresses the theoretical concepts, elements of interpretation and applications of the CBCT scan in endodontics. In addition, the contents and rationale for reporting 3D endodontic imaging are discussed.

Keyword

Cone-beam computed tomography; Endodontics; Interpretation; Review

Figure

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  Figure 1 Volumetric observation planes. (A) Side view. (B) Front view. (C) Sagittal view of the oblique planes of a lower incisor. (D) Axial view of the oblique planes of a lower incisor. (A-D) Yellow: axial plane, pink: sagittal plane, blue: coronal plane.

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  Figure 2 The ability of cone-beam computed tomography (CBCT) to identify vertical fractures is affected by several factors: (i) size of the fracture line < 80 µ and/or smaller than the CBCT voxel size. (ii) Noise/artifact in the image related to endodontic treatment, intra-radicular posts and ceramic/metallic restorations. (iii) Noise/artifact produced by patient movement during the CBCT scanning [11]. In the aforementioned clinical case, the CBCT revealed a relatively localized pattern of bone loss on the coronal plane (buccal area of the mandibular molar), which is a very typical tomographic finding in patients in which vertical fracture is suspected [11].

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  Figure 3 Voxel in endodontics. Image quality comparison concerning different voxel sizes. (A) Premolar image 90 μm voxel; (B) 200 μm voxel; (C) > 200 μm voxel.

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  Figure 4 Field of view (FOV) sizes. (A) Large FOV (78–150 mm). (B) Medium FOV (61–78 mm). (C) Small FOV (≤ 50 mm).

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  Figure 5 Clinical applications of cone-beam computed tomography (CBCT) in endodontics. (A-C) Endodontic surgery: multiple navigation planes enable the planning of surgical procedures while preserving the integrity of anatomical structures (mental nerve) nearby the operative site. Root resorption: the perforating aspect of the internal root resorption (E) may be seen in the sagittal plane thanks to 3-dimensional navigation. Neither periapical radiography (D) nor the examination of the coronal plane (F) can yield this finding. Dens invaginatus: (G) initial periapical radiograph suggesting the possibility of an atypical tooth anatomy. The classification (type 1) of the dens invaginatus can be determined by navigating the axial (H) and sagittal planes (I) of the CBCT scan. The sagittal plane (I) enables the relationship between the invagination and the main root canal to be confirmed. Type-I dens invaginatus without connection to the main canal is seen at the cervical level. Vertical root fracture: (J) initial endodontic fistulography. Vertical root fractures typically exhibit dehiscence-type bone defects that are seen on the CBCT in conjunction with a single, narrow periodontal pocket (K). However, clinical validation of these results is required (L). Missed canals: (M) endodontic sinus tract suggesting endodontic failure. Axial and sagittal planes (N, O) confirm the presence of an MV2 missing canal. (P) Clinical validation of tomographic findings.

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  Figure 6 (A) View in the 3 orthogonal planes and 3-dimensional (3D) volume of an entire mandible (large field of view [FOV]). Note the amount of noise/artifacts generated in a large scan volume that outputs a low image resolution. (B) View in the 3 orthogonal planes and 3D volume of a segment in the maxilla (small FOV). Note the high resolution of the image generated in a more specific scanning.

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  Figure 7 Treatment planning under the development of static/dynamic navigation protocols. (A-F) Guided endodontic for managing a canine with a coronal and cervical calcified canal. (A, B) 40 × 50 mm field of view (FOV) and 75 µm voxel cone-beam computed tomography (CBCT) scan with endodontic access guide design. (A) Virtual 3-dimensional (3D) template. (B) CBCT image of the canine with model scan aligned to the 3D template. (C-F) Guided endodontic treatment clinical sequence. (G-L) Guided endodontic microsurgery “Bone Window” technique. (G, H) 40 × 50 mm FOV and a 75 µm voxel CBCT scan with a 3D template design for osteotomy using the cortical window approach. (I, J) Rectangular osteotomy using piezoelectric saws. (K) Representative linear measurements of the periapical lesion obtained with the CBCT scan and the location of the inferior alveolar nerve. (L) Post-surgery (2D image). (M-T) Guided auto-transplantation of maxillary molar. (M, N) 40 × 50 mm FOV and a 75 µm voxel CBCT scan with tooth segmentation of the left maxillary third molar (tooth #28) from CBCT images. (O, P) 3D model of maxillary molar (tooth #28) and 3D template design to guarantee proper insertion into the receiving socket (left maxillary second molar [tooth #27]). (Q, R) Clinical auto-transplantation procedure with printed replica tooth (tooth #28) in a suitable position for placement of the natural donor tooth afterwards. (S, T) 2D radiographic follow-up. (U, V) Computer-aided dynamic navigation (Navident, ClaroNav, Ontario, Canada). Training on the dynamic navigation process using a biomodel.

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  Figure 8 Cone-beam computed tomography (CBCT) volumetric data display mode options. Multiplanar Reformatting (MPR) includes linear oblique, curved oblique, and serial trans-axial imaging. Ray sum is comprised of increased thickness section images. Volumetric rendering consists of indirect volumetric rendering (IVR) and direct volumetric rendering (DVR). Adapted from Scarfe et al. [33].

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  Figure 9 Suggested cone-beam computed tomography (CBCT) endodontic report adapted from Patel et al. [45].FOV, field of view.

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  Figure 10 Most common cone-beam computed tomography-related artifacts in endodontics. (A) Noise. (B) Beam hardening. (C) Movement.

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