Cone Beam Computed Tomography in Endodontics (Inglês)
Cone Beam Computed Tomography in Endodontics (Inglês)
Cone Beam Computed Tomography in Endodontics (Inglês)
3 MARCH
Dental Bulletin
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.
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
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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).
Fig 3a Normal bone around Fig 3b CBCT shows the periapical tooth 47 lesion at the mesial root
Fig 2a Symptomatic tooth 24 despite apparently satisfactory root canal fillings and absence of periapical lesion.
Fig 2d Untreated MB2 canals in both 16 and 17. Note 16MB canal was stripped perforated
Fig 4b Multiple resorptive lacunae and widened periodontal ligament space at 11 suggest cervical root resorption. Internal resorption in 21
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Dental Bulletin
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
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).
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.
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References
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