Cone Beam Computed Tomography in Endodontics (Inglês)

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VOL.11 NO.5 MAY 2006 2010 VOL.15 NO.

3 MARCH

Dental Bulletin

Cone Beam Computed Tomography in Endodontics


Dr. SF LEUNG
BDS(HK), MSc(Lond.), FRACDS
Specialist in Endodontics, Part-time Lecturer, Faculty of Dentistry, The University of Hong Kong

Dr. SF LEUNG

Introduction
Conventional (both chemical and digital) radiography renders a three-dimensional (3-D) anatomical structure two dimensionally with inherit distortions. This limitation posts a steep learning curve for novice operators to interpret information from the resulting images. In many incidences, it becomes a matter of guesswork even to the experienced user, like the relationship of the maxillary molars with the maxillary sinus. Cone beam computed tomography (CBCT) has been used in dentistry since 19981. Unlike medical CT, which captures the image in slices, CBCT data are captured in a 3-D pixel unit called voxel. As these voxels are isotropic, the object is accurately measured in different directions. This enables the rendering of geometrically undistorted images of the maxillo-facial skeletal structure and allows viewing at different angles. In addition to providing higher resolution image, CBCT has a much reduced radiation dosage than medical CT. The exposure, at about three to ten times the radiation of a digital panoramic radiograph, is more comparable to routine diagnostic imaging with panoramic and periapical radiography. CBCT is available with different fields of view (FOV) to suit different applications. In endodontics, a machine with limited FOV should suffice. CBCT has become a routine tool in oral surgery and especially implant dentistry. With increasing affordability of the computer and less expensive CB Xray tube, CBCT will have enormous potential in endodontics. The following case reports illustrate some of these endodontic applications.

Case Reports
Case 1 - C Shaped Mandibular Second Molar Teeth
Approximately 42% of fused-root mandibular second molars of Hong Kong Chinese patients might be associated with a C-shaped root canal system2. This common anatomical variation presents a challenge to root canal treatment. The difficulties include locating and cleaning of the canal system3, and instrumentation mishaps4. Periapical radiograph alone is not adequate to distinguish c-shaped root canal pattern from fused roots with separate canals. This Chinese patient had what looked like a two-rooted 47 (Fig 1a). Symptoms persisted despite instrumentation of both canals (Fig 1b). The case was referred and treated under the operating microscope, which revealed the c-shaped canal pattern (Fig 1c). The symptom was relieved after completion of treatment (Fig 1d). If a pre-operative CBCT were taken, a couple of treatment visits could be saved. Fig 1e shows another case with c-shaped root canals in both 37 and 47.

Fig 1a Tooth 47 appeared to have conical root with 2 root canals.

Fig 1b Both canals identified and cleaned

Summary
The advantages of CBCT includes 1. Three dimensional rendition 2. Geometrically accurate images 3. Increased sensitivity and specificity for caries, periodontal and periapical lesions 4. Patient comfort - no intra-oral placement of film or sensor. 5. Soft tissue rendition Disadvantages 1. Increased radiation 2. Expensive 3. Inferior resolution 4. Beam scatter and hardening by high density materials cause artifacts 5. Dentist/DSA needs to be computer savvy

Fig 1c C-shaped canal pattern revealed under the operating microscope

Fig 1d Final obturation of the cshaped canal system

Fig 1e CBCT showing c-shaped canal pattern in both 37 and 47

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Dental Bulletin
Case 2 - Extra Root/Canal
This patient complained of persistent discomfort from tooth 24 despite apparently satisfactory root canal treatment. The periapical radiograph revealed satisfactory root canal fillings without periapical change (Fig 2a). As the pain radiated to the cheek and zygoma area, a CBCT was taken to check for missing root canal and possible sinus problem. The CBCT revealed an untreated MB root canal (Fig 2b). The symptom was relieved after retreatment was performed (Fig 2c). Maxillary molars, particularly the MB roots, present problems frequently. The MB2 canal should be considered as the norm rather than the exception. They are revealed readily with the CBCT (Fig 2d).

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Fig 3a Normal bone around Fig 3b CBCT shows the periapical tooth 47 lesion at the mesial root

Fig 3c and a large distal lesion

Fig 3c and a large distal lesion Fig 3d 47 completed root treatment

Case 4 - Cervical Resorption


This patient was referred by his general dentist for the management of the two non-vital upper central incisors. The teeth suffered traumatic injury more than 20 years ago and became discoloured over the last few years. Both teeth did not respond to pulp tests. The periapical radiograph showed there was pulpal sclerosis, together with small periapical lesions with both teeth (Fig. 4a). There were radiolucent lesions in the root of 11. It was difficult to determine the nature of the resorptive lesions. A CBCT was acquired and revealed multiple resorptive lacunae inside the pulp chamber of 11 (Fig. 4b). The diagnosis was cervical resorption of 11 and internal resorption of 21. Treatment of 11 would be challenging due to the coexistence of cervical resorption and total pulpal sclerosis. Substantial tooth tissue has to be removed to gain access to these lacunae. The surgical procedure would be traumatic and destructive. As the tooth has been asymptomatic over these many years and the resorption process was slow, the patient decided not to take treatment but to keep the tooth under periodic reviews. The root treatment of 21 was completed uneventfully (Fig 4c).

Fig 2a Symptomatic tooth 24 despite apparently satisfactory root canal fillings and absence of periapical lesion.

Fig 2b Untreated MB root revealed

Fig 2c Retreatment of all canals

Fig 2d Untreated MB2 canals in both 16 and 17. Note 16MB canal was stripped perforated

Case 3 - The "Hidden" Radiolucencies


The CBCT gives improved sensitivity and specificity in diagnosis of periapical lesions over conventional radiographs 5. The analyses of diagnostic methods showed that apical periodontitis was detected more frequently when CBCT was used, compared with periapical radiograph6. This patient complained of persistent poorly located discomfort from his lower right posterior teeth. Tooth 47 was heavily restored but responsive to pulp tests. The tooth appeared normal on periapical radiograph (Fig 3a). No crack tooth was suspected in the region and the opposing dentition. There was hesitation to remove the filling for further investigation due to the potential cumulative pulpal injury from repeated operative procedure7. A CBCT revealed a periapical lesion that was not evident on the periapical radiograph (Fig 3b). Root canal treatment was instituted. The pulp was confirmed necrotic on opening. The treatment was completed uneventfully and the pre-operative symptom was cured (Fig 3d). The confronting post-operative problem is whether CBCT will be required for periodic reviews. This will imply high radiation and cost. A radiologist will be consulted.

Fig 4b Multiple resorptive lacunae and widened periodontal ligament space at 11 suggest cervical root resorption. Internal resorption in 21

Fig 4a Non-vital 11 and 21 with pulpal sclerosis and resorption

Fig 4c Root treatment of 21

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VOL.11 NO.5 MAY 2006 2010 VOL.15 NO.3 MARCH

Dental Bulletin

Case 5 - Internal Resorption


This patient presented with buccal and lingual sinuses at tooth 36. The periapical radiograph showed radiolucent patches in and around the mesial root (Fig 5a). The CBCT revealed extensive root perforations due to internal resorption (Fig 5b, c, d). The prognosis of the tooth was poor and it was extracted.
Fig 6a Fig 6b 36 periapical lesions increase in size despite adequate root fillings, a) at 4/2008, and b) at 4/2009

Fig 5a Radiolucency at 36 mesial root

Fig 5b CBCT showing perforating defects and perioendo lesion (arrows) Fig 6c Coronal section showing mental foramen (IDN), apical granuloma (AG) and sinus tract opening (SO)

Fig 5c Fig 5d CBCT showing perforating defects and perio-endo lesion (arrows)

Fig 6d Immediate post operative radiograph showing resected roots and retrograde fillings

Case 6 Pre-surgical Assessment for Apicectomy


This patient was referred by her general dentist for the management of a deteriorating periapical lesion at 36. The tooth was root filled to a high standard under rubber dam isolation a few years ago. However the periapical lesion increased in size, together with the emergence of a buccal discharging sinus (Fig 6a, b). It would be less likely to achieve a successful outcome if conventional retreatment was attempted in failed cases with technically satisfactory treatment8. An apicectomy with retrograde filling was planned, as the case could be infected by more resistant bacteria/fungi, or suffering from an extra-radicular infection9, a radicular cyst10. 11, or a foreign body reaction12. Furthermore the possibility of apical root fracture13 could be explored at the same time. The periapical radiographs showed the mental foramen was in close proximity with the mesial root and the periapical lesion. A CBCT was acquired to provide a geometrically accurate assessment of the relationship between them and the 'space' available for surgical manipulation 14 (Fig 6c). It would also show any potential missed canal. After apicectomy and curettage, an anastomosis between the mesial canals was identified. It was prepared with endosonics and retrofilled with MTA (Fig 6d). The patient experienced minimal mental parasthesia, which recovered completely six weeks after surgery. The case is under active review.

Other Related Applications


Simon et al15 claimed that the CBCT could distinguish between periapical granuloma and radicular cyst in 13 out of 17 cases. However this has not been substantiated by others. CBCT is superior to conventional radiography for the diagnosis of horizontal root fractures16, and is proved valuable for real time assessment in maxillo-facial trauma diagnosis and treatment17. The resolution of the CBCT is low at 2 lines per mm (lpmm)18 compared with conventional (chemical and digital) intraoral periapical film with 15-20 lpmm19. This is not adequate to reveal except the more extensive vertical root fractures (VRF) (Fig 7).

Fig 7 VRF of 17MB and 27MB. Detection of VRF with CBCT is exception rather than the rule

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Dental Bulletin
This lack of resolution, however, does not affect the superiority of CBCT in the assessment of periodontal regeneration, caries and bone lesions20, 21, 22. The image on the scan is well demarcated and provides better sensitivity and specificity than conventional radiograph. However the scatter and beam hardening could significantly affect the image occasionally (Fig 8).

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Fig 8 In this case of an endo perio lesion of tooth 26, beam scattered from the root fillings render this scan useless in revealing the untreated MB2 canal and vertical root fracture

Conclusion
The CBCT is a valuable adjunct to the endodontists' armamentarium. The learning curve is not steep and variability of clinical interpretation is low. However it is a sophisticated tool, requiring special skills for operating the machine and the image manipulation afterwards. Like any equipment in the digital age, continuous evolution and refinement is anticipated. Extra hidden expenses in depreciation and upgrades have to be added to the initial installation cost. In conclusion the CBCT is a useful tool for the diagnosis and management of endodontic problems. Its use is becoming increasingly popular but some machines are better suited for endodontic purposes than others. The operators should consider their specific needs before making the move to acquiring one in the office.

11. Nair PN, Sjogren U, Schumacher E et al (1993) Radicular cyst affecting a root-filled human tooth: a long-term post-treatment follow-up Int Endodon J;26:225-233. 12. Nair PN, Sjogren U, Krey G et al (1990) Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth J Endodon 16;12:589-595. 13. Adorno CG, Yoshioka T, Suda H (2009) The Effect of root preparation technique and instrumentation length on the development of apical root cracks J Endodon 35;3:389-392. 14. Uchida Y, Noguchi N, Goto M et al (2009) Measurement of anterior loop length for the mandibular canal and diameter of the mandibular incisive canal to avoid nerve damage when installing endosseous implants in the interforaminal region: a second attempt introducing cone beam computed tomography. J Oral Maxillofac Surg. 67;4:744-50. 15. Simon JSH, Enciso R, Malfaz J-M et al (2006) Differential diagnosis of large periapical lesions using cone-beam computed tomography measurements and biopsy J Endodon 32;9:833-837. 16. Bornstein MM, Wolner-Hanssen AB, Sendi P (2009) Comparison of intraoral radiography and limited cone beam computed tomography for the assessment of root-fractured permanent teeth Dental Traumatol 25;6:571-577. 17. Chow BKC, Chow JKF (2009) Application of office base threedimensional technologies including cone-beam computed tomography and rapid prototyping in the management of maxillofacial trauma-literature review and a case report. Hong Kong Dent J 6;2:93-97. Hong Kong Dent Asso, Hong Kong. 18. Yamamoto K, Ueno K, Seo K et al (2003) Development of dentomaxillofacial cone beam X-ray computed tomography system. Orthodon Cranfac Res 6(Suppl. 1) 160-2. 19. Farman AG, Farman TT (2005) A comparison of 18 different x-ray detectors currently used in dentistry Oral Surg Oral Med Oral Pathol Oral Radiol 1Endodontol 99;4:485-489. 20. Grimard BA, Hoidal MJ, Mills MP et al (2009) Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy J Periodontol 80;1:48-55. 21. Young SM, Lee JT, Hodges RJ et al (2009) A comparative study of high-resolution cone beam computed tomography and chargecoupled device sensors for detecting caries Dentomaxillofac Radiol. 38;7:445-51. 22. Noujeim M, Prihoda T, Langlais R et al (2009) Evaluation of highresolution cone beam computed tomography in the detection of simulated interradicular bone lesions Dentomaxillofac Radiol. 38;3:156-62.

References
1. Mozzo P, Procacci C, Tacconi A et al (1998) A new volumetric CT machine for dental imaging based on the cone-beam technique: preliminary results. Euro Radiol 8;9:1558-64. 2. Cheung LH, Low D, Cheung GS (2006) Root morphology--a study of the mandibular second molar of ethnic Chinese. Ann R Aust Coll Dent Surg 18:47-50. 3. Gao Y, Fan B, Cheung GS et al (2006) C-shaped canal system in mandibular second molars part IV: 3-D morphological analysis and transverse measurement J Endodon 32;11:1062-1065 4. Cheung LH, Cheung GS (2008) Evaluation of a rotary instrumentation method for C-shaped canals with micro-computed tomography J Endodon 34;10:1233-8 5. Wu M-K, Shemesh H, Wesselink PR (2009) Limitations of previously published systematic reviews evaluating the outcome of endodontic treatment Int Endodon J 42;8:656-666. 6. Estrela C, Reis Bueno M, Rodrigues Leles C et al (2008) Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis J Endodon 34;10:273-9. 7. Langeland K, Langeland LK (1970) Pulp reactions to cavity and crown preparation Aust Dent J 15;4:261-76. 8. Farzaneh M, Abitbol S, Friedman S (2004) Treatment outcome in endodontics: The Toronto Study. Phases I and II: orthograde retreatment J Endodon 30;9:627-633. 9. Sunde PT, Olsen I, Debelian GJ et al (2002) Microbiota of periapical Lesions Refractory to Endodontic Therapy J Endodon 28;4:304-310. 10. Simon JH . (1980) Incidence of periapical cysts in relation to the root canal . J Endodon 6;11:845-848.

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