doi:10.1111/iej.

13115

REVIEW
Cone beam computed tomography in
Endodontics – a review of the literature

S. Patel1,2 , J. Brown3, T. Pimentel1 , R. D. Kelly1, F. Abella4 & C. Durack5

1
Department of Conservative Dentistry, King’s College London Dental Institute, London; 2Specialist Practice, London;
3
Department of Maxillofacial & Dental Radiology, King’s College London Dental Institute, London, UK; 4Universitat
Internacional de Catalunya, Barcelona, Spain; and 5Speciailist Practice, Limerick, Ireland

Abstract The aim of this paper is to: (i) Review current literature
on the endodontic applications of CBCT; (ii) Based on
Patel S, Brown J, Pimentel T, Kelly RD, Abella F,
current evidence make recommendations for the use of
Durack C. Cone beam computed tomography in
CBCT in Endodontics; (iii) Highlight the areas in which
Endodontics – a review of the literature. International
more research is required.
Endodontic Journal, 52, 1138–1152, 2019.
Keywords: cone beam computed tomography,
The use of cone beam computed tomography (CBCT) in
endodontic diagnosis, management of endodontic
the diagnosis and/or management of endodontic prob-
problems, radiography.
lems is increasing and is reflected in the exponential
rise in publications on this topic in the last two decades. Received 12 December 2018; accepted 11 March 2019

dimensional nature of CBCT overcomes some of these

Introduction
limitations (Patel et al. 2015).
The three-dimensional radiographic assessment of There are insufficient data within meta-analyses or
teeth and their surrounding structures with cone systematic reviews assessing the use of CBCT in
beam computed tomography (CBCT) is desirable for Endodontics. Therefore, the aim of this review is to
aiding diagnosis and/or management of complex present the most relevant literature highlighting the
endodontic problems (Rodr
ıguez et al. 2017a,b). relative advantages and also disadvantages of CBCT
The use of CBCT in Endodontics is increasing rapidly in the various aspects of Endodontics.
worldwide, and this is reflected in position statements
being published by several specialist societies (European Radiological aspects of CBCT
Society of Endodontology 2014, American Association
of Endodontists/American Academy of Oral & Maxillo- Cone beam computed tomography is a modification of
facial Radiology CBCT position statement 2015). the computed tomography (CT) concept, involving the
The limitations of conventional radiography are single rotation of an X-ray source around the dental
well established. The diagnostic yield of the two- subject.
dimensional images generated (Brynolf 1967, Velvart The data are analysed and reconstructed using a
et al. 2001) is impaired, to varying degrees, by CT-based algorithm to create a volume of data, which
anatomical noise masking the area of interest (Bender can be viewed in three conventional planes (axial,
& Seltzer 1961, Paurazas et al. 2000) and geometric sagittal and coronal) and multiple alternative planes
distortion (Forsberg & Halse 1994). The three- on manipulation of the data set.
Image acquisition is rapid and uses technology,
which is becoming relatively affordable. A three-
Correspondence: Shanon Patel, 45 Wimpole Street, London dimensional visualization of the region of interest is
W1G 8SB, UK (e-mail: shanonpatel@gmail.com). obtained in sufficient detail to localize teeth and

1138 International Endodontic Journal, 52, 1138–1152, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Patel et al. CBCT in Endodontics – a review

adjacent anatomy in a manner, which is simply not Article 18 of the EURATOM 2013 directive requires
achievable with conventional, 2D, plain dental film that individuals are ‘adequately trained’ for any role
imaging. they play in the radiographic imaging of a patient.
The legislation makes general requirements for train-
ing in radiation protection but does not generally
Dosages, their reduction and optimization
define what specific ‘adequate training’ should be for
The potential benefits of CBCT must be balanced with any particular radiographic technique or modality. As
the comparatively higher levels of risk from radiation such, it falls to specialist and expert bodies to draw
exposure, compared to conventional imaging. up guidelines that define what training would be
Mean effective doses for large, medium and small appropriate. Cone beam computed tomography train-
field of views (FOV) CBCT scans have been measured ing needs to familiarize the user with the principles of
to be 212, 177 and 84 lSv, respectively (Ludlow CBCT imaging and highlight how it differs from con-
et al. 2015). The range for a small field of view is 5 – ventional dental imaging so that it can be applied
146 lSv, but many machines achieve a reasonable correctly. Crucially, the user needs to be aware of the
exposure of around 30 lSv on manufacturer’s default very specific advantages and disadvantages of this
settings. For comparison, a panoramic radiograph is technique over other dental imaging and be able to
normally between 16 and 20 lSv (Ludlow et al. balance the potential benefits with the possible detri-
2015). mental effects of increased radiation exposure.
Dose reduction is therefore focused on optimizing Two levels of training are to be recommended by
exposure parameters on an individual basis the European Academy of Dentomaxillofacial Radiol-
(Table 1). Each examination should be tailored to ogy (Brown et al. 2014) and by Public Health Eng-
the individual patient and their diagnostic needs, land in the UK. A ‘core course’ (level 1 training) is to
rather than just assuming manufacturer’s default set- be undertaken by those prescribing CBCT scans. An
tings are the most appropriate ones. Every attempt ‘advanced training’ (level 2 training) is recommended
should be made to understand and maximize the for those interpreting CBCT scans. The training
capability of the CBCT unit to generate diagnostically should ideally take place over 12 h and through a
suitable images to enhance endodontic diagnosis and variety of methods: lectures, seminars, hands-on and
management. face-to-face exercises, case-based discussions, group
tutorials, distance learning and online teaching
(Brown et al. 2014).
Training and education
Cone beam computed tomography is sufficiently new
Specific requirements for endodontics
to have been given little exposure in undergraduate
dental training to date, and so there is a need for Cone beam computed tomography imaging in
both newly qualified and established dentists to learn Endodontics requires exceptionally high detail and
about this new technique so that they can employ it resolution to appreciate the intricacies of the root
effectively and use it safely. canal system and periodontium. High image resolu-
tion comes at the cost of higher patient radiation
exposure.
Only small FOV CBCT scans are recommended for
Table 1 The dose (in lSv) will be increased by: the diagnosis and management of endodontic prob-
Exposures that include the salivary glands in the FOV (e.g. lems. A small FOV scan reduces the volume of
posterior mandible > anterior maxilla) exposed tissue, and therefore, the effective radiation
Larger FOVs
dose, but, favourably, this also reduces scatter, which
Higher kV
Higher mA
improves image quality. The generated images may
Higher exposure time (e.g. full rotation vs half rotation, or be easily degraded by subtle patient movement; the
more versus reduced number of basis images, or continuous most suitable machines for maintaining patient stabil-
versus pulsed X-ray beam) ity are where the patient sits, or even lies down,
Smaller voxel size (not an automatic dose increase, but often
rather than stands (Spin-Neto et al. 2015). This is an
the manufacturers compensate for the greater noise in small-
voxel images by increasing exposure)
important consideration when using CBCT imaging,
as the dedicated CBCT units are often designed for a

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1138–1152, 2019 1139
 CBCT in Endodontics – a review Patel et al.

seated or supine patient whilst hybrid panoramic/ • Post-graduate endodontic programmes should
CBCT units usually have the patient standing. The incorporate the use of CBCT.
trend for hybrid panoramic/CBCT units appears to be
the predominant growth area in CBCT imaging cur-
Assessment of periapical periodontitis
rently, most probably because these units are cheaper
yet multifunctional. However, it must be recognized Periapical radiography (PR) is the accepted reference
that image quality is at risk of being lower. standard for the radiological detection of AP (ESE 2006).
However, anatomical noise may hide early stages of AP-
related periapical bone destruction (Bender & Seltzer
Limitations
1961, Tsai et al. 2013, Kanagasingam et al. 2017a).
The presence of metallic restorations (e.g. amalgam This can lead to difficulty in the diagnosis of early signs
restorations, metal posts and/or crowns, and implants) of endodontic disease, especially in cases where clinical
or even gutta-percha can cause significant radio- signs and symptoms indicate pulp necrosis or irreversible
graphic artefact, sufficient to compromise details of pulpitis (Abella et al. 2012a, 2014, Kruse et al. 2015).
root canal anatomy and relevant pathosis such as root
resorption and root fractures. Metal artefact reduction
Detection of apical periodontitis
algorithms (MAR) are becoming more common in
operating and viewing software in order to overcome It is well established from the results of ex vivo studies
this disadvantage (Queiroz et al. 2018a). These are with reference standards, that is where the periapical
mathematical post-processing programmes which anal- status is known beforehand, that CBCT is more accu-
yse an area of image where streak, beam hardening rate than PR to detect periapical periodontitis (Patel
and photon starvation artefact are found, and analyse et al. 2009a,b, Sogur et al. 2009, Ahlowalia et al.
the adjacent ‘normal’ image to deduce what grey 2013, Liang et al. 2013).
shades should be found in the boundary zones immedi- Patel et al. (2012a) detected periapical lesions in
ately adjacent to the artefact. These grey shades are 20% and 48% of 123 teeth planned for primary root
then applied in the affected areas of the image where canal treatment when PR and CBCT were used,
information is deficient, essentially smoothing the respectively. Similar findings have been reported in
image and approximating the true detail. This is, how- other studies (Davies et al. 2015, Uraba et al. 2016,
ever, open to error, and resultant images may reduce Torabinejad et al. 2018) (Table 2).
accurate fine detail (Bechara et al. 2013a) and so Results of in vivo dog studies, using histological
images generated with artefact reduction programmes block dissections as the reference standard, have
are to be used with caution. These programmes are corroborated the findings of the aforementioned
only truly effective in full rotation scans (Queiroz et al. ex vivo and clinical studies, concluding that CBCT is
2018b). They are particularly effective when compen- more accurate than PR for diagnosing AP in root
sating for artefacts around metal objects and are less filled teeth in dogs (Paula-Silva et al. 2009a). These
effective when employed to compensate for artefacts results have been also confirmed by Kanagasingam
adjacent to gutta-percha (Bechara et al. 2012, Queiroz et al. (2017b) in a comparative study using histo-
et al. 2018a). The efficacy of the programmes is fur- logical block dissections of fresh human cadavers as
ther improved when the offending metal object is in a reference standard. Using human cadavers as a
the centre of the field of view (Queiroz et al. 2017). reference standard, Kruse et al. (2018) concluded
that the diagnosis of AP was dependent on the
‘treatment status’ of the tooth. The diagnostic accu-
Concluding remarks:
racy of CBCT was high with almost all cases of AP
• A CBCT scan should be tailored to the individual being diagnosed correctly in non-root filled teeth;
patient and their diagnostic needs; however, the diagnostic accuracy was lower for root
• The potential benefits of the CBCT scan should filled roots.
outweigh the potential risks; Cone beam computed tomography may reveal the
• Clinicians must regularly update their core knowl- presence of previously undiagnosed pathoses (Nakata
edge in CBCT; et al. 2006). Cone beam computed tomography may
• Undergraduate curricula should include an intro- also be indicated to assist in confirming the absence
duction to CBCT radiology; of an odontogenic aetiology of pain when PR

1140 International Endodontic Journal, 52, 1138–1152, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Patel et al. CBCT in Endodontics – a review

Table 2 Clinical studies comparing the detection of periapi- teeth with no preoperative signs of AP (Ng et al.
cal lesions between CBCT and periapical radiographs (PR) in 2011). Thus, earlier identification of AP with CBCT
untreated and endodontically treated teeth may result in earlier diagnosis and treatment of
Primary endodontic treatment endodontic disease.
The increased accuracy of CBCT images in identify-
CBCT > PR Teeth
ing periapical radiolucencies should result in a more
Estrela et al. 2009 39% 83 (untreated) objective and accurate assessment of the outcome of
Patel et al. 2012a,b 28% 151 (untreated)
pulp preservation, primary root canal and secondary
Abella et al. 2012a,b 11% 128 (irreversible)
Abella et al. 2014 19% 161 (non-vital) root canal treatment as well as periapical micro-
surgery (Liang et al. 2011, Davies et al. 2016).
Secondary endodontic treatment
Paula-Silva et al. (2009b) published the first root
CBCT > PR Teeth canal outcome study using CBCT. They compared the
Lofthag-Hansen et al. 2007 20% 46 (re-rct) outcome of root canal treatment in dogs using PR
Estrela et al. 2009 28% 1425 (re-rct) and CBCT. Six months after treatment, a favourable
Low et al. 2008 34% 74 (re-rct) outcome was detected in 79% of teeth assessed with
Bornstein et al. 2011 26% 38 (re-rct) PR, but in only 35% when CBCT was used. Unfavour-
Cheung et al. 2013 30% 60 (re-rct)
able outcomes occurred more frequently in single-visit
Venskutonis et al. 2014 25% 35 (re-rct)
Davies et al. 2015 30% 100 (re-rct) root canal treatment than two-visit treatments.
Uraba et al. 2016 21% 178 (re-rct) Liang et al. (2011) assessed the radiographic qual-
ity of root canal treatment carried out in teeth with
Primary + secondary endodontic treatment
vital pulps at 2 years with PR and CBCT. In 41% of
CBCT >
cases, there was a difference in the quality of root fill-
radiographs Teeth
ings, with CBCT revealing more poor-quality root fill-
Weissman et al. 2015 22% 67 (untreated + re-rct) ings than periapical radiographs. Root filling voids
Cone beam computed tomography was associated with a were detected in 16% and 46% of cases with PR and
greater prevalence of periapical lesions when compared to PR CBCT, respectively; the majority (77%) of voids evi-
(11%–39%).
dent on CBCT scans were in the bucco-lingual plane.
When assessed with CBCT, root filling quality, that is
examination is unremarkable (Patel 2009, Pigg et al. the absence of voids, and quality of coronal restora-
2011, ESE 2014). tions were determined to be prognostic factors in the
Small periapical lesions which may not be readily outcome of the treatment. In a follow-up study, Liang
detected with PR may be detected with CBCT. This et al. (2013) compared the outcome of root canal
may have an impact on treatment planning in cases treatment with and without ultrasonic activation of
of gross caries and/or pulpitis where a decision irrigants and found no difference in outcome.
between endodontic treatment and conservative treat- Patel et al. (2012b) assessed the outcome of pri-
ment must be made (Hashem et al. 2015, 2018, Patel mary root canal treatment using PR and CBCT,
& Vincer 2017). 1 year after treatment. The healed and healing rate
The radiographic appearance of a healthy periodontal of AP was 87% and 62.5% (healed), and 95.1% and
ligament is more variable when assessed with CBCT 84.7 (healing), when assessed with PR and CBCT,
compared to PR (Pigg et al. 2014), and therefore, a respectively. CBCT detected a 14 times higher failure
healthy periodontium may be misdiagnosed as diseased. rate in teeth with no preoperative periapical radiolu-
The importance of suitable training is essential. It has cency at 1-year review. Using the same methodology
been shown that the clinician’s experience also appears to assess the outcome of retreatment cases, similar
to be correlated to their ability to correctly diagnose peri- results were observed by Davies et al. (2016). Both
apical disease on CBCT scans (Parker et al. 2017). these studies revealed that treatment of molar teeth
had a lower success rates than that of anterior and
premolar teeth.
Assessment of the outcome of root canal treatment
Al-Nuaimi et al. (2017) concluded that a favour-
It is well established that the root canal treatment of able outcome was more likely when at least 30%
teeth with radiographic signs of chronic apical peri- residual tooth structure was present at the com-
odontitis has poorer (radiographic) outcomes than mencement of root canal retreatment. In a pooled

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1138–1152, 2019 1141
 CBCT in Endodontics – a review Patel et al.

analysis of 354 root filled teeth (123 primary treat- affords the clinician the ability to preoperatively assess
ments and 231 retreatments), the success rate for the entire surgical field without restriction, facilitating
root canal treatment was lower when assessed using the surgical procedure.
CBCT compared to PR. Furthermore, molar teeth had
a significantly poorer success rate than premolar and
Detection of apical periodontitis and identification
anterior teeth (Al-Nuaimi et al. 2018).
of affected roots
Fern
andez et al. (2013), using PR and CBCT, retro-
spectively assessed the outcome of root canal treat- In multi-rooted teeth, the ability to identify specific
ment carried out on teeth with vital pulps 5 years roots with AP allows the clinician to be root-specific
previously. Of 17 prognostic factors assessed, four fac- (Kraus et al. 2015) and eliminate the removal of alve-
tors appeared to have a negative impact on the out- olar bone and dentine associated with unaffected
come of treatment when assessed with CBCT. These roots, all of which serve to improve patient comfort,
were root canal curvature, disinfection of gutta- simplify the procedure and reduce treatment time and
percha, unidentified root canals and the quality of the cost.
coronal restoration. However, these results should be Cone beam computed tomography permits the
interpreted with caution as no pre-treatment CBCT accurate assessment of the dimensions and extent of
scans were taken. the lesion as well as its relationship to adjacent
anatomical structures and the presence of any expan-
sion or perforation of cortical bone (Bornstein et al.
Concluding remarks
2012). This aids planning, for example flap design,
• Due to the limitations of conventional radiogra- and limits unnecessary excavation of lesions which
phy, the size of periapical lesions is underestimated are in close proximity to vital neighbouring
when compared to CBCT; structures.
• Current evidence suggests that CBCT has a higher Digital Imaging and Communications in Medicine
sensitivity than PR for the detection of periapical (DICOM) data sets may be used to fabricate custom
lesions; surgical guides for tissue retraction and root-end
• Cone beam computed tomography may be indi- location in teeth undergoing apical surgery (Patel
cated to aid the diagnosis of (non-)odontogenic et al. 2017, Ye et al. 2018).
pain when clinical examination and conventional
radiographic assessment are not clear;
Assessment of the root, root canal and the
• Cone beam computed tomography may be consid-
surrounding anatomical structures and landmarks
ered when (in)direct pulp capping or pulpotomy is
relevant to apical surgery
being planned in extensively carious teeth where
PR does not reveal anything untoward. Cone beam computed tomography is a diagnostically
accurate and reliable tool for the measurement of root
length (Liang et al. 2013, Metska et al. 2014); the
CBCT for pre-surgical assessment
identification of the apical foramen (Jeger et al. 2012,
Cone beam computed tomography has been advo- Liang et al. 2013); the assessment of root, and root
cated as a useful diagnostic aid and treatment plan- canal, anatomy and curvature (Park et al. 2013); and
ning tool in cases of endodontic surgery (Tsurumachi the presence and position of bone defects (Low et al.
& Honda 2007, Low et al. 2008, Durack & Patel 2008). Accurate identification of anatomical struc-
2012). The inter-individual and regional, intra-indivi- tures and landmarks reduces operative morbidity.
dual variations in the dimensions and location of Pre-treatment evaluation will enhance patient com-
anatomical structures including, and contained fort and minimize treatment time and complexity.
within, the alveolar bone surrounding teeth, compli- These precise assessments cannot be accurately
cate the endodontic surgical procedure. Cone beam undertaken with PR.
computed tomography provides a more reliable and Bornstein et al. (2011) compared the ability of PR
effective method for identification of missed anatomy and CBCT to measure the distance between the apices
and accessory canals as well as the true nature and of mandibular molars and the inferior dental nerve
extension of a periapical lesion (Bornstein et al. 2015, canal in teeth undergoing apical surgery. This dis-
Patel et al. 2015). Cone beam computed tomography tance could only be measured accurately in 35.3%

1142 International Endodontic Journal, 52, 1138–1152, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Patel et al. CBCT in Endodontics – a review

and 100% of cases using PR and CBCT, respectively. information (Patel et al. 2015); in reality, it is likely
The thickness of the cortical plate and the combined that CBCT offers much more than an adjunctive role
thickness of cortical plate and cancellous bone could in the assessment of TDI.
also be measured accurately using CBCT, measure-
ments that simply cannot be made with periapical Injuries to the hard tissues and dental pulp
radiography. von Arx et al. (2013) used CBCT to
evaluate the location and dimensions of the mental Crown fractures. Cone beam computed tomography
foramen as well as the course and angulation of the may provide a more objective assessment of the thick-
mental canal exiting the mental foramen. They ness of the dentine overlying the pulp (Tsukiboshi &
related this information, using CBCT, to the position Durack 2016).
of adjacent teeth and to that of the upper and lower
borders of the mandible. Crown root fractures. Cone beam computed tomogra-
The orientation of the long axis of the root to the phy permits a more accurate visualization of the
cortical plate can be determined with CBCT so that course of the often oblique nature of these fractures
correct bur orientation and depth of cut for root resec- and the relationship of the fracture to the pulp, peri-
tion can be planned prior to treatment. Identification odontium and crestal bone, thus facilitating manage-
of root canals missed clinically, or indeed, verification ment (Martos et al. 2017, Dogan et al. 2018).
of the absence of supplemental canals is enhanced by
CBCT (Lofthag-Hansen et al. 2007, Davies et al. 2015). Horizontal root fractures. Horizontal root fractures
So too are the identification of isthmi (Soares de (HRF) generally have an oblique orientation when
Toubes et al. 2012) and anomalous tooth forms (Song they occur in the apical and middle thirds of the root
et al. 2010, Durack & Patel 2011, Radwan & Kim and can only be identified with PR when the X-ray
2014) in teeth which may require endodontic surgery. beam passes within 15–20° of the orientation of the
fracture line (Bender & Friedland 1983, Andreasen &
Andreasen 1988). As such, these injuries may be
Concluding remarks
missed with PR, but they are reliably identified with
CBCT is recommended for: CBCT (Jones et al. 2015, Tsukiboshi & Durack 2016).
• Complex surgical cases (i.e. multi-rooted teeth and By altering CBCT exposure parameters, the radia-
complex anatomy); tion dose may be reduced by up to 80% with little
• When the root apices are in close proximity to impact on the diagnostic yield in the detection of HRF
important anatomical structures or where these (Jones et al. 2015).
structures cannot be accurately assessed with PR.
Injuries to the periodontal tissues
Dental trauma
Concussion and Subluxation. Cone beam computed
Contemporary guidelines for the management of trau- tomography is significantly more sensitive than PR in
matic dental injuries (TDI) advocate that an anterior the detection of PDL space widening and in the detec-
occlusal radiograph should supplement the findings of tion of incipient lesions of apical periodontitis (Cheung
two periapical radiographs when an injured tooth is et al. 2013, Tsai et al. 2013). Therefore, in severe
assessed (Di Angelis et al. 2012). Additional radio- subluxation injuries with significant tooth mobility,
graphs to assess any lip and cheek lacerations are fur- widening of the PDL space may only be evident on
ther advised to identify potential embedded debris. CBCT; this may influence the management (Tsuki-
Even with these additional radiographs, the true nat- boshi & Durack 2016, Patel & Saberi 2018).
ure of TDIs is often extremely difficult to visualize.
Luxation injuries (lateral luxation, intrusive luxation and
extrusive luxation). The nature of luxation injuries may
Use of CBCT to assess TDI
not always be readily appreciated from a clinical exami-
Cone beam computed tomography provides enhanced nation, especially in mixed dentition, and/or where
visualization of TDIs over PR (Di Angelis et al. 2012, there are concomitant dental injuries, for example lat-
Tsukiboshi & Durack 2016) and has been indicated eral luxation in conjunction with intrusion or extrusion
in situations where PR provides limited diagnostic (Tsukiboshi & Durack 2016). With PR, it may be very

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1138–1152, 2019 1143
 CBCT in Endodontics – a review Patel et al.

difficult to visualize the bucco-palatal orientation of Root resorption

these injuries (Cohenca et al. 2007, Tsukiboshi & Dur-
The limitations of PR can result in misdiagnosis, inad-
ack 2016). IADT guidelines advise that lateral luxation
equate assessment and/or poor management of root
injuries are best viewed using eccentric or occlusal con-
resorption (Schwartz et al. 2010, Gunst et al. 2013,
ventional radiographic exposures (Di Angelis et al.
Patel & Saberi 2018). Several ex vivo studies have
2012) to some degree, leaving radiographic visualiza-
confirmed a greater level of accuracy with CBCT for
tion to chance. Cone beam computed tomography per-
diagnosing internal (Kamburo glu et al. 2011) and
mits unobstructed visualization in all planes facilitating
external resorption defects (Durack et al. 2011, Ber-
accurate assessment of the nature of the displacement
nardes et al. 2012, Vaz de Souza et al. 2017).
(Cohenca et al. 2007, Tsukiboshi & Durack 2016).
The bucco-palatal extent of internal and external
root resorptive lesions can only be accurately assessed
Injuries to the supporting bone with CBCT. This information may be relevant when
Fractures of the alveolar plates(s) occur as a matter determining the prognosis of treatment (Patel et al.
of course with lateral luxation and intrusive luxa- 2010, Bhuva et al. 2011).
tion injuries (Di Angelis et al. 2012). Regardless of Estrela et al. (2009) found that CBCT and PR
the nature of the fracture, they are rarely if ever detected inflammatory root resorption in 100% and
identified with PR. This is in contrast to CBCT 68.8% of cases, respectively. Patel et al. (2009b)
which is sufficiently sensitive to identify the nature found that CBCT was significantly better than PR in
of alveolar bone damage in the absence of any evi- correctly diagnosing clinical root resorption, and this
dence on PR (D€ olekoglu et al. 2010, Tsukiboshi & resulted in more appropriate treatment planning. Sim-
Durack 2016). ilar conclusions have been found in more recent clini-
This information may have an impact on treatment cal studies (Ee et al. 2014, Patel et al. 2016,
planning, for example, when extraction and immedi- Rodr
ıguez et al. 2017a,b, b).
ate implant placement are being considered. The ‘portal of entry’, as well as the true nature of
the resorptive lesion, may not be readily detectable on
Injuries to the soft tissues PR (Mavridou et al. 2016, Patel et al. 2018a). In
The ‘scout views’ taken to confirm the size and positioning addition, the true nature of ECR (fibrovascular and
of the field of view prior to scanning, as well as the CBCT bone-like tissue) will also be more clearly discernible
images, capture and display the exact location of any radio- with CBCT (Gunst et al. 2013), information, which is
dense matter embedded in the soft tissues within a given relevant for treatment planning (Patel & Dawood
examination (Tsukiboshi & Durack 2016). 2007, Patel et al. 2018a).
The Heithersay (1999) classification does not take
in account the circumferential spread or depth of
Concluding remarks
ECR. Vaz de Souza et al. (2017) created simulated
The effective radiation doses with CBCT are higher ECR lesions representing the four Heithersay classes
than PR, and this must be balanced against the larger and found that CBCT was significantly more accurate
number of PRs that must be prescribed in an attempt than PR at classifying ECR. In a clinical study, Patel
to yield the same information that can be obtained et al. (2016) concluded that PR had a limited accu-
from a single CBCT scan. Cone beam computed racy in the detection of the size, circumferential
tomography should be considered: spread and location of ECR lesions compared to CBCT.
• When the diagnosis from clinical and PR assess- The additional information gained from CBCT has
ment is inconclusive; resulted in the introduction of a 3-dimensional classi-
• When there are severe injuries to multiple teeth; fication to describe ECR (Patel et al. 2018b). The aim
• When DTI results in it being impossible to acquire of this descriptive classification is to ensure an accu-
PR due to patient discomfort and/or limited mouth rate diagnosis and aid communication of ECR
opening; between clinicians. It should allow objective outcome
• Thought should be given to using CBCT as the tool assessment as well as aid in decision-making. Ulti-
of choice in reviewing traumatically injured teeth mately, treatment outcome and prognostic factors
to allow earlier detection of complications (e.g. may also be assessed in relation to the three-dimen-
resorption). sional nature of ECR.

1144 International Endodontic Journal, 52, 1138–1152, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Patel et al. CBCT in Endodontics – a review

Concluding remarks management (Kajan & Taromsari 2012). Scatter from

radiopaque materials may be misinterpreted as frac-
In cases where (parallax) radiographs provide limited
ture lines (Hassan et al. 2010, Kajan & Taromsari
information, CBCT should be considered as an addi-
2012).
tional method to assess the nature of a resorptive
The presence of metallic posts decreases the diag-
lesion; this information improves diagnosis and man-
nostic yield of CBCT scans in the detection of root
agement of root resorption.
fractures due to the presence of beam hardening arte-
facts (Costa et al. 2011). In contrast, fibre posts do
Vertical root fractures (VRF) not seem to interfere with the sensitivity and speci-
ficity CBCT in the detection of VRF (Neves et al.
PR only detect VRF if it they are displaced and in the
2014, Pinto et al. 2017).
plane of the X-ray beam (Rud & Ommell 1970, Meis-
ter et al. 1980) and in situations where there is mini-
mal anatomical noise (Patel et al. 2013, Brady et al. Clinical research
2014).
Wang et al. (2011) concluded that the sensitivity of
CBCT was higher than PR in the assessment of 95
root fractures. However, the accuracy was impaired
Ex vivo investigations
by the presence of a root filling due to scatter from
Several ex vivo studies have highlighted that CBCT the radiopaque root filling material (Wang et al.
examinations have a greater accuracy at detecting 2011). In a meta-analysis, Long et al. (2014) sug-
simulated VRF (Tsesis et al. 2008, Hassan et al. gested that CBCT has a high diagnostic yield for the
2009). detection of tooth fractures, with a reported sensitivity
The heterogeneity between studies (Talwar et al. and specificity of 0.92 and 0.85, respectively.
2016), not least the method of fracture induction, Chavda et al. (2014) evaluated PR and CBCT
which in some studies has produced widely displaced images and compared them to atraumatically
fractured segments, which would be clinical detect- extracted teeth in order to confirm the presence or
able (0.2 mm–0.4 mm), means that the studies have absence of a fracture. They reported a sensitivity of
questionable clinical relevance (Hassan et al. 2009, 0.16 and 0.27 for PR and CBCT, respectively, and a
Kamburo glu et al. 2010). To overcome this, fractures relatively high specificity of 0.92 and 0.83 for PR and
have been induced by applying a compressive load to CBCT, respectively.
a pin inserted into the root (Patel et al. 2013, Brady A systematic review highlighted the heterogeneity
et al. 2014). In these studies, a universal testing of the available data and a high risk of bias, which
machine was used to detect the development of the led the authors to conclude that CBCT may be of lim-
fracture. The overall accuracy for detecting both types ited value in detecting VRF in root filled teeth (Chang
of fractures with CBCT was 0.87 and 0.45 for non- et al. (2016). This is also in agreement with other
root filled teeth and root filled teeth, respectively. The systematic reviews (Corbella et al. 2014, Rosen et al.
diagnostic accuracy of PR was 0.63 and 0.53 for 2015).
non-root filled teeth and root filled teeth, respectively.
Detectability also appears to be CBCT scanner-speci-
Concluding remarks
fic (Elsaltani et al. 2016, Tiepo et al. 2017). The
detector sensitivity, voxel parameters, exposure There is insufficient evidence to advocate the use of
parameters, speed and degree of scan rotation, and CBCT for detection of VRF. However, CBCT may be
variations in image reconstruction have an impact on indicated where symptoms and/or signs are absent or
the accuracy of CBCT (Bechara et al. 2013b, Bezerra ambiguous and VRF is suspected. In these cases,
et al. 2015, Talwar et al. 2016). CBCT may reveal signs of periradicular bone loss indi-
Beam hardening resulting from the root filling cating a VRF within the adjacent root.
reduces the specificity of incomplete and complete
fracture detection in root filled teeth (Schulze et al.
Assessment of root canal anatomy
2011, Khedmat et al. 2012, Neves et al. 2014). As a
result, diagnosis becomes more challenging (Bechara Due to the two-dimensional nature of PR, they are
et al. 2013c), which may result in inappropriate likely to underestimate the true anatomical

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1138–1152, 2019 1145
 CBCT in Endodontics – a review Patel et al.

complexity of the root canal system (Matherne et al. There is poor inter-examiner variation associated
2008, Abella et al. 2012b, Davies et al. 2015). with treatment of endodontic pathoses (Reit &
Ex vivo research has demonstrated a significant and Gr€ondahl 1988). Ee et al. (2014) compared the rela-
predictable benefit to using CBCT examinations in tive value of preoperative PR and CBCT in the deci-
identifying additional roots of mandibular molars (Tu sion-making process in endodontic treatment
et al. 2009). Matherne et al. (2008) reported that planning. Three American board-certified endodontists
endodontists failed to identify at least one canal in up separately selected a preoperative diagnosis of 30 ran-
to 41% of cases when evaluated with PR when CBCT domly arranged sets of PR, and then 2 weeks later,
was used as the gold standard. Abubara et al. (2013) they reviewed 30 CBCT scans of the same teeth. The
reported that only 8% of MB2 canals were identified treatment plan changed with CBCT in 62% of the
using PR, whilst with CBCT, MB2 canals were identi- cases. Similar results were reported by Mota de
fied in 54% of cases. Almeida et al. (2015) and Rodr
ıguez et al. (2017a).
Cone beam computed tomography examination Davies et al. (2016) concluded that CBCT had an
improves the identification, location and appreciation impact of the future management of retreatment cases
of teeth with anomalous anatomy, for example dens attending for a review when compared to PR.
invaginatus (Patel 2010, Durack & Patel 2011). More Rodr
ıguez et al. (2017a) assessed the impact of CBCT
recently, CBCT has been used in conjunction with on decision-making amongst different specialists
specialized software (3DEndoâ, Dentsply Sirona, Bal- (prosthodontists, endodontists, oral surgeons and peri-
laigues, Switzerland) to evaluate the complexity of odontists). Thirty cases with endodontic problems of
root canals (Gambarini et al. 2018) prior to treat- varying degrees of complexity (n = 10 minimum,
ment. Patel et al. (2019) found 3DEndoâ, software, n = 10 moderate and n = 10 high difficulty) were
followed by CBCT, was found to be more desirable for assessed. Examiners were given relevant clinical infor-
the evaluation of root canal anatomy, working mation and PR, and selected the most appropriate treat-
lengths and also reducing the clinician’s stress levels ment plan and graded the difficulty in decision-making.
than PR. A recent three-dimensional classification of One month later, the examiners reviewed the same 30
various dental anomalies based on CBCT investiga- cases with the additional information from the CBCT.
tions has been devised (Ahmed & Dummer 2018). The authors concluded that the additional information
Stents with guide sleeves have been 3D printed obtained from CBCT scans influences the treatment plan
from optical surface scans and CBCT data sets to of each specialist group, in high difficulty cases the treat-
allow guided access cavity preparation (Connert et al. ment plan changed in up to 53% of cases. With the
2019). The benefits of guided access cavity prepara- exception of endodontists, the different groups of special-
tion include conservative access cavity preparation, ists reported a relatively high difficulty in decision-mak-
decreased chair time and reduced risk of iatrogenic ing when viewing the CBCT scans. This may have an
damage (Torres et al. 2018, Connert et al. 2019). impact on other specialist groups assessing endodontic
problems with CBCT imaging – it may be prudent to seek
an endodontist’s opinion in these cases.
Concluding remarks
Rodr
ıguez et al. (2017b) determined the impact of
Cone beam computed tomography imaging may be CBCT imaging on decision-making amongst general
indicated to obtain information about the nature of dental practitioners and endodontists after failed root
complex root canal anatomy. CBCT gives an increased canal treatment. The examiners altered their treat-
appreciation of the root canal anatomy, which should ment plan after viewing the CBCT in 49.8% of the
result in more conservative access preparation. The cases. After viewing the CBCT scans, examiners’ selec-
poor resolution of CBCT means that sclerosed and/or tion of the option to extract teeth rose from 11.67%
accessory anatomy may not be readily identified. to 20%.

Impact on treatment planning Concluding remarks

Treatment options for root canal retreatment failure Diagnostic CBCT may provide additional information
include non-surgical or surgical endodontic retreat- when compared to PR, which may an impact on the
ment, intentional replantation and extraction with treatment planning of complex endodontic retreat-
(out) tooth replacement. ment cases.

1146 International Endodontic Journal, 52, 1138–1152, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Patel et al. CBCT in Endodontics – a review

Conclusion Al-Nuaimi N, Patel S, Austin R, Mannocci F (2017) A pro-

spective study assessing the effect of coronal tooth struc-
It is clear that the additional information provided by ture loss on the outcome of root canal retreatment.
CBCT may increase and/or improve diagnostic accu- International Endodontic Journal 50, 1143–57.
racy and confidence in decision-making as well as Al-Nuaimi N, Patel S, Davies A, Bakhsh A, Foschi F, Man-
have an impact of treatment planning. More clinical nocci F (2018) Pooled analysis of 1-year recall data from
studies are required to assess the long-term impact of three root canal treatment outcome studies undertaken
CBCT on the outcomes of endodontic treatment. using cone beam computed tomography. International
However, CBCT imaging comes at the expense of Endodontic Journal 51, e216–26.
increased radiation dose; therefore, CBCT should only Andreasen JO, Andreasen FM (1988) Resorption and miner-
alization processes following root fracture of permanent
be reserved for cases where there is potential benefit
incisors. Endodontics and Dental Traumatology 4, 202–14.
from a three-dimensional assessment. It is essential
von Arx T, Friedli M, Sendi P, Lozanoff S, Bornstein M
that patient radiation exposure is kept as low as rea- (2013) Location and Dimensions of the Mental Foramen:
sonably practicable (ALARP). The benefits of a CBCT a Radiographic Analysis by Using Cone-beam Computed
investigation must outweigh any potential risks. Tomography. Journal of Endodontics 39, 1522–8.
Therefore, each scan must be optimized to reduce Bechara B, Moore WS, McMahan CA, Noujeim M (2012)
patient exposure by adjusting the CBCT settings, thus Metal artefact reduction with cone beam CT: an in vitro
allowing each examination to be personalized to the indi- study. Dentomaxillofacial Radiology 41, 248–53.
vidual patient and the diagnostic needs, rather than just Bechara B, McMahan CA, Moore WS, Noujeim M, Teixeira FB,
using manufacturer’s default settings. Geha H (2013a) Cone beam CT scans with and without arte-
Users of CBCT must attend accredited training on fact reduction in root fracture detection of endodontically
treated teeth. Dentomaxillofacial Radiology 42, 20120245.
the core (level 1) and/or advanced (level 2) training
Bechara B, McMahan CA, Nasseh I et al. (2013b) Number of
depending on their level of use.
basis images effect on detection of root fractures in
endodontically treated teeth using a cone beam computed
Conflict of interest tomography machine: an in vitro study. Oral Surgery, Oral
The authors have stated explicitly that there are no Medicine, Oral Pathology, Oral Radiology 115, 676–81.
conflicts of interest in connection with this article. Bechara B, McMahan CA, Noujeim M et al. (2013c) Compar-
ison of cone beam CT scans with enhanced photostimu-
lated phosphor plate images in the detection of root
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