1

Uses for Cone Beam Computed Tomography In Endodontic

Care
Three-dimensional radiography is a helpful adjunct that supports accurate endodontic
diagnosis, case planning and treatment.
By Brooke Blicher, DMD and Rebekah Lucier Pryles, DMD On Jan 10, 2020

The field of endodontics has long embraced technology in its efforts to improve the quality of
care. Rotary instruments, electronic apex locators and surgical operating microscopes have
expedited and improved endodontic care. They have also led to improved
outcomes.1 Comparable to these advances, the advent of cone beam computed tomography
(CBCT) has propelled the field to greater heights. It offers a unique technological advantage in
endodontic care, as it not only greatly facilitates the diagnosis of endodontic pathology,2 it also
has proven useful as a treatment aid.3

The more this three-dimensional (3D) imaging modality is utilized, the more applications are
discovered. While CBCT imaging is not recommended for routine screening, several position
statements on the topic demonstrate recognition by organized dentistry of its increasing
utility.4 Though CBCT technology may not be available in every clinical situation, its increasing
availability in both general and specialty offices assures access to this important tool by
referral in most communities. Thus, in cases where CBCT will clearly aid diagnosis and/or
treatment, clinicians must consider its use. Though it is clear CBCT should be employed in cases
in which insufficient information is present to make a definitive diagnosis, the appearance of
incidental, unexpected findings that may alter the treatment plan warrants consideration of
broader application (Figures 1A and 1B). In fact, research demonstrates that many clinicians
change their proposed treatment plans after reviewing CBCT findings.5 This article will review
applications for CBCT in diagnosis and treatment planning, as well as in the direct delivery of
endodontic care — from access through posttreatment follow-up imaging.
 2

FIGURES 1A and 1B. Incidental lesions that

become apparent on cone beam computed tomography may alter the treatment plan — such as
in the case of this external cervical resorptive lesion found on the mesiobuccal root of tooth
#19. It was
discovered while working up a tooth with pulpal necrosis and acute apical abscess (A, B).
As an imaging modality, CBCT greatly surpasses two-dimensional (2D) radiographic techniques
in its ability to detect endodontic disease. The resulting images are dimensionally
accurate,6 eliminating concerns over distortion with conventional 2D radiography. This
dimensional accuracy facilitates precise measurement of endodontic pathology. Unlike
conventional radiographs that are limited by anatomic noise, or the overlay and artifact from
adjacent bone and anatomic structures that mask pathology,7 CBCT scans are not subject to
anatomic noise. Consequently, these images are capable of detecting smaller areas of
radiographic pathology located exclusively within cancellous bone. Conversely, traditional
radiographs can only detect pathology that has escaped the confines of cancellous bone into the
surrounding cortex.7 Consequently, 3D radiography eliminates the need for multiple angles of
periapical imaging traditionally required to fully visualize pathosis. If one considers that
radiation from limited-field-of-view CBCT is only two to three times greater than periapical
imaging, the gain in information with CBCT is easily justified.

DIAGNOSIS
 3

As a diagnostic tool, CBCT possesses particular utility in cases involving:

• Difficult-to-localize symptoms
• Areas subject to anatomic noise
• Diagnosis of previously endodontically treated teeth
• The workup of traumatic dental injuries
• Assessment of resorptive lesions
• Fracture diagnosis

A common indication for CBCT relates to cases with a potentially difficult diagnosis due to
contradictory clinical signs and symptoms, or otherwise hard to localize pain.4,8 When
insufficient information is obtained from a clinical or traditional radiographic exam, a CBCT
scan can be utilized to pinpoint a definitive site of endodontic pathosis (Figures 2A and 2B). In
cases of pain associated with previously treated teeth, 3D imaging may better pinpoint the
cause of treatment failure — namely, missed anatomy or fracture pathology. The absence of
radiographic changes can suggest a non-endodontic source of pain, such as traumatic occlusion,
sinus issues or even neuropathic pain. In these cases, CBCT imaging is a unique tool to confirm
or refute endodontic disease as an etiology.

FIGURES 2A and 2B. An

example of contradictory clinical findings noted with cone beam computed tomography. The
patient presented with clinically replicable cold hypersensitivity consistent with a symptomatic
 4

irreversible pulpitis, as well as a palatal sinus tract adjacent to tooth #3 (A). Three-dimensional
imaging revealed the unexpected source as external cervical resorption on the palatal root of
tooth #3 (B).
As CBCT images are dimensionally accurate and not limited by anatomic noise, they are two
times more likely to detect periapical radiolucencies than periapical radiography alone.2 This
improved sensitivity is an obvious benefit in terms of its utility as a diagnostic tool. In addition
to its generally greater ability to detect apical pathology, 3D imaging is of further use in areas
subject to significant anatomic noise.9 For example, due to the anatomic noise of the maxillary
sinus and zygomatic process, periapical imaging of the posterior maxilla can miss about a third
of lesions picked up by CBCT.6 Furthermore, early changes to the maxillary sinus — namely,
development of localized maxillary sinus mucositis that can precede definitive endodontic
lesions — may be easily detected with CBCT.10 Beyond identifying the exact location or source
of an infection, this imaging modality can identify the extension of periapical lesions in relation
to other important anatomic structures. This can play a role in the monitoring of neighboring
teeth or ill effects of untreated disease. Sinus tracts, traditionally traced by gutta-percha, can be
accurately assessed by localization of cortical plate breakthrough for increased diagnostic
accuracy.

The use of CBCT is considered routine in the workup of traumatic dental injuries, suspected
resorption or fractures, and in previously treated teeth.4 Oral trauma can involve multiple
subsets of injuries, and the acute nature of such diagnoses warrants careful identification of
fractured teeth and jaws, as well as displacement of teeth in bone. The American Association of
Endodontists’ Guidelines for the Management of Traumatic Dental Injuries suggest that CBCT
imaging, when available, should be utilized in baseline evaluations.11 These images can help
identify and demonstrate the extent of both tooth and alveolar fractures, as well as guide
subsequent surgical repositioning or interdisciplinary treatment planning. For luxation-type
injuries, including concussion, subluxation, and lateral, intrusive and extrusive luxation
injuries, 3D imaging should be utilized to visualize the periodontal ligament space and directly
identify displacements. In managing avulsive injuries, CBCT imaging post-replantation can
confirm positioning and rule out associated cortical plate fractures.

This advanced imaging technology is also essential in the accurate diagnosis and subsequent
treatment of resorptive dental diseases. Resorptive dental diseases are multifaceted, and their
management and prognosis are specific to the location, extent and type of resorption. As
resorption is not often localized to just the mesial and distal aspects of teeth visible by
traditional radiography, CBCT imaging is an obvious choice to fully visualize the exact location,
 5

extent and type of resorptive defect. Periapical imaging will significantly underestimate the
size, circumferential spread and location of external cervical resorption.12 By comparison, CBCT
imaging not only enhances the correct localization of this pathology, it also has been shown to
significantly alter clinicians’ chosen treatment plans.12 Likewise, it can greatly aid in the
differentiation of internal root resorption and external cervical resorption. It further allows for
direct visualization of potential sources of resorption, namely, endodontic pathology that can
cause apical external inflammatory root resorption, misaligned erupting teeth or non-
odontogenic pathology that may cause pressure resorption.

In a limited capacity, CBCT imaging can detect root fractures.13 Fracture lines can be detected
only when they are of a diameter larger than the resolution of the image.13 As vertical root
fractures occur with greatest frequency in previously endodontically treated teeth (oftentimes
restored with metallic posts), artifacts can render fractures even harder to detect.14 That said,
3D images often show indirect findings associated with fractures, rather than the fracture lines
themselves (Figures 3A and 3B). This imaging modality can detect localized areas of bone loss
suggestive of root fractures, particularly areas of midroot bone loss with intact bone coronal
and apical to the defect, loss of the entire buccal cortical plate, midroot radiolucencies in the
area of termination of a post, and space between the buccal and lingual cortical plate and root
surface.15 These areas may be seen as the classical “J-shaped” or “halo” radiolucency on
traditional radiography, but considering that fractures are not confined to the mesial and distal
aspects of the tooth, the use of CBCT will allow for broader identification of such lesions.

FIGURES 3A and
3B. Cone beam computed tomography may not show fracture lines directly, but can showcase
indirect findings, such as localized vertical bone defects (A, B).

RETREATMENT CASES
Previously treated teeth with existing endodontic fillings offer another routine consideration
for CBCT. Whether pathology is visible on traditional radiography or not, pain in a previously
 6

endodontically treated tooth warrants a CBCT scan. If apical pathology is not seen in an
otherwise completely filled root with an adequate coronal seal, clinicians can often rule out
endodontic disease as a contributing factor. If apical pathology is present, consideration should
be given to the potential etiology of the failure. Initially untreated anatomy is an obvious
potential reason for failure that can be improved upon with root canal retreatment by a skilled
provider. Cases with evidence of an initial poor-quality root fill have the best prognosis
following nonsurgical root canal retreatment.16 Prior complications — including overextension
of root filling materials and separated instruments that may negatively impact retreatment —
can be visualized using CBCT, which helps improve assessment of retreatment options.

When considering surgical retreatment procedures, CBCT is indispensable in the identification

of adjacent anatomic considerations, including the size and extent of pathology, nuances in root
anatomy, and proximity to important structures, including the maxillary sinus and mandibular
nerve canal.17 Previously endodontically treated teeth may fail for reasons not entirely related
to the endodontic procedure — such as developing root fractures or perforations — and CBCT
imaging can be a useful adjunct for identifying these etiologies when nonsurgical or surgical
endodontic retreatment is unlikely to be successful.

It is evident that CBCT imaging can have a great impact on endodontic diagnosis. It follows then
that treatment planning should be positively affected by its use. Research demonstrates that
when clinicians evaluate cases, first using traditional periapical radiographs, and two weeks
later with CBCT imaging, their diagnosis and treatment plans change 62% of the time.5 This
number increases when the provider deems the case more difficult, and is more likely to
include extraction when CBCT scans are utilized.18 Given its ability to help practitioners develop
better treatment plans, the justification for image exposure is clear, particularly in complex
cases.

FIGURES 4A through 4C. Cone beam computed tomography (CBCT) used preoperatively can
 7

map out complex anatomy, ensuring efficient and complete nonsurgical endodontic treatment,
such as this split in the apical one-third of the distal root of tooth #18. Preoperative periapical
(A), preoperative CBCT (B), postoperative periapical (C).

ENDODONTIC TREATMENT
Beyond diagnosis and treatment planning, CBCT scans have great utility in enhancing the
delivery of endodontic care. As the surgical operating microscope enhanced clinicians’ abilities
to visualize canal anatomy, locating previously unreachable canals and managing calcification,
CBCT provides a road map before an access is even made. Gone are the days of searching for
that suspected second mesiobuccal canal in a maxillary molar (present 95% of the time).19 With
use of a preoperative CBCT, clinicians have definitive knowledge of the location and numbers of
canals in the tooth prior to treatment. The benefit of this anatomic knowledge extends beyond
lessened pain and long-term failures. Prior knowledge of the nuances of treatment will result in
efficiencies directly benefiting the patient in reduced treatment time, local anesthesia and
patient fatigue (Figures 4A through 4C). The dimensional accuracy of CBCT scans allows for
accurate working length estimation in cases in which an electronic apex locator is
inaccurate.20 Future applications of CBCT may involve the creation of surgical guides, like those
used in implant dentistry.3

When considering nonsurgical retreatment procedures, knowledge of the locations of

previously untreated anatomy allows for considerable improvement in treatment outcomes
(Figures 5A through 5D). Similarly, when planning for surgical care, preoperative CBCT
imaging helps operators plan the best approach to expose the lesion, anticipate sinus
involvement, and avoid anatomically challenging spaces, such as the mandibular or
nasopalatine nerve canals.17

Beyond the utility of pretreatment CBCT images in care delivery, this imaging modality can be
used as an intratreatment adjunct to help locate suspected anatomy. Removing the dental dam
and exposing a CBCT scan can illuminate the direction of endodontic access and allow for
corrections when searching for calcified canals. These images can also be used to identify
intraoperative complications, such as perforations or transportations. Unique applications
have been discussed in the literature, such as using CBCT to carefully map out a dens
invaginatus, allowing for its conservative management.21
 8

FIGURES 5A through
5D. Treatment of previously endodontically treated teeth (A)
should begin with preoperative cone beam computed tomography (B). As shown here, an
untreated second mesiobuccal canal was the likely source of recurrent infection, and
addressing this via nonsurgical root canal retreatment resulted in apical healing (C, D).

POSTTREATMENT FOLLOW-UP
This imaging modality also allows more efficient monitoring of the healing process (Figures 5A
through 5D). In cases where posterior maxillary endodontic pathology has resulted in adjacent
maxillary sinus mucositis, healing of both the apical pathology and mucositis can also be
monitored with CBCT imaging during postoperative evaluations.

Furthermore, when compared to periapical radiography, earlier evidence of healing will be

seen with 3D imaging. When lesions extend to the lateral surfaces of other roots, monitoring for
early healing can ensure that adjacent teeth remain healthy. Of course, CBCT scans — like
traditional radiography — cannot help providers determine whether a lesion is pathologic or
scar tissue, and new evidence suggests this more sensitive means of radiography will result in
remaining apical radiolucencies in 20% of previously endodontically treated teeth.22 Thus, it is
important for providers to consider how the patient is healing, as well as clinical signs and
symptoms, in making any determination of success or failure.
 9

CONCLUSION
Though its usefulness in endodontic treatment is becoming more apparent, CBCT imaging is
still considered an adjunctive tool. It does not replace critical review of the patient’s history,
clinical characteristics, and traditional bitewing and periapical radiographs. Extensive
restorative histories involving metallic materials can create beam hardening artifacts and
scatter that can greatly reduce the diagnostic yield of an image,23 and caries is still best detected
through bitewing radiographs. Due to the need for thorough diagnosis, clinicians must engage
in continuing education to ensure accuracy in reading CBCT images and enlist the help of a
licensed oral radiologist for over-reads whenever necessary.

Ultimately, CBCT imaging is a tool to enhance the management of endodontic pathosis that
should be applied when existing information is inadequate or inconclusive (Table 1). That said,
its broad utility in endodontic diagnosis, treatment and follow-up should not be
underestimated.

KEY TAKEAWAYS

• Cone beam computed tomography (CBCT) offers a unique technological advantage in

endodontic care.
• This imaging modality not only greatly facilitates the diagnosis of endodontic
pathology,2 it also has proven useful as a treatment aid.
• While CBCT is not recommended for routine endodontic screening, several position
statements demonstrate recognition by organized dentistry of its increasing utility.4
• Three-dimensional radiography eliminates the need for multiple angles of periapical
imaging traditionally required to fully visualize endodontic pathoses.
 10

• Research demonstrates that many clinicians change their proposed treatment plans
after reviewing CBCT findings.5
• This imaging modality also allows more efficient monitoring of the healing process.
• Ultimately, CBCT imaging is a tool to enhance the management of endodontic pathosis
that should be applied when existing information is inadequate or inconclusive.