Cone Beam Computed

Tom o g r a p h y U p d a t e d
Tec h n o l o g y f o r En d o d o n t i c
Diagnosis
Randolph Todd, DMD

KEYWORDS
 Cone beam computed tomography  Radiographic diagnosis
 3-dimensional radiology  Radiographic outcome assessment
 Root canal morphology  Endodontic diagnosis  Apical periodontitis

KEY POINTS
 Narrow field CBCT has many applications in Endodontics and reduces the negative effects
of anatomic noise, geometric distortion and technique sensitivity observed on 2D images.
 Narrow field CBCT provides earlier detection of apical periodontitis than conventional 2D radio-
graphs providing improved diagnostic value, treatment efficiency and outcome assessment.
 Narrow field CBCT provides excellent image resolution at reduced radiation exposure as
compared to mid or large field of view CBCT.
 CBCT assists the practitioner to identify canal morphology, numbers of canals and relative
positioning even in the presence of calcific metamorphosis and dystrophic calcifications.
 Identification and treatment of lateral canals is supported by viewing their specific location
with the use of narrow field of view CBCT before or during endodontic therapy.

INTRODUCTION

According to the Merriam-Webster dictionary, the term “diagnosis” is defined as:

“the art or act of identifying a disease from its signs and symptoms.” In the field of
endodontics, dentists review a multitude of signs and symptoms to formulate their
diagnosis. These include, but are not limited to: sensitivity to heat, sensitivity to
cold, percussion, palpation, bite, swelling, caries, periodontal disease, presence of si-
nus tracts, and unstimulated pain. In addition to these symptoms, tests are used to
identify variations from normal such as electric pulp tests,1 laser Doppler,2 and radio-
graphs3 (first used in 1896 by Otto Walkhoff). In the early 1960s Seltzer and Bender4,5
identified several discrepancies using 2-dimensional (2D) radiographs for observing

Department of Endodontics, Stony Brook University School of Dentistry, Sullivan Hall, Stony
Brook, NY 11794, USA
E-mail address: drrandolphtodd@gmail.com

Dent Clin N Am 58 (2014) 523–543

http://dx.doi.org/10.1016/j.cden.2014.03.003 dental.theclinics.com
0011-8532/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
524 Todd

apical periodontitis (AP). These included: (a) a delayed appearance of radiographic ev-
idence of AP until 40% cortical plate demineralization developed and (b) a lack of cor-
relation between the size of the histologic defect and AP image.
In addition, according to Durack and Patel, 2D radiographs are of limited value due
to the compression of 3-dimensional (3D) structures, geometric distortion, anatomic
noise, and temporal perspectives.4–6
Radiographs are used to identify the changes inside visually opaque objects.
Although interpretations of these images are only part of the diagnostic process, the
dental community places great emphasis on this information. In the early 1970s, Bry-
nolf studied the benefit of using radiographs from multiple angles to increase their
diagnostic value. She found that using 3 images improved diagnosis significantly.7
Later that decade, grave concerns developed. Many articles published supported
the idea that reading dental radiographs was too subjective.8–10 To this concern,
Orstavik and colleagues12 developed a guide to standardize apical observations
called the Periapical Index. Despite these efforts, 2D radiographs were still limited
in diagnostic value due to the factors previously listed.4–6
Computer-assisted tomographic imaging or cone beam computed tomography
(CBCT), a technology borrowed from medicine, previously focused on the need for
better surgical guidance during implant placement.14 The principle of ALARA21 (As
Low As Reasonably Achievable) as related to radiation exposure and the lack of res-
olution initially limited CBCT use in endodontics.15 A new area of research emerged,
and old paradigms were shifting.17 These advances solved many of the listed 2D lim-
itations.6,13 Specific applications of this technology developed and the Endodontic
community embraced them.18–20
The current narrow field of view CBCT provides a 3D, low-radiation/high-resolution so-
lution to many endodontic diagnostic and treatment problems.11 This article will display
specific case scenarios and supporting literature for the application of CBCT technology.

ROOTS: ANATOMIC NOISE HIDES ANATOMY

Case #1: Maxillary Left First Bicuspid—Diagnosis: Pulpal Necrosis/Symptomatic Apical
Periodontitis
Identification of root structure, curvature, and location are hampered in 2D radio-
graphs by anatomic noise (Fig. 1).6 In this case, CBCT (Figs. 2 and 3) assisted with

Fig. 1. Preoperative 2D periapical x-ray, arrow pointing to hidden radicular anatomy

“Anatomic Noise”.
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Fig. 2. 3D CBCT sagittal view shows 2 buccal roots (arrow).

Fig. 3. 3D CBCT coronal view shows buccal and palatal roots (arrow).

the preoperative identification of the presence, location, shape, and lengths of 3

separate distinct roots. Note the accurate orientation, size, and location of apical
periodontitis clearly observed on sagittal (see Fig. 2) and coronal views (see
Fig. 3).16 Treatment is clearly supported by preoperative knowledge of root
anatomy.

CANALS: HIDDEN CANAL MORPHOLOGY

Case #2: Mandibular Left First Molar, Diagnosis: Irreversible Pulpitis/Symptomatic
Periodontitis
Preoperative identification of the number, location, and length of canals is facilitated
with a CBCT scan (Figs. 4–7). Successful endodontic treatment depends on treating
all canals (see Fig. 7).22 In tooth #19, a midmesial canal is observed on the preoper-
ative axial scan (see Fig. 5) and verified clinically (see Fig. 6).
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Fig. 4. Preoperative 2D view periapical x-ray.

Fig. 5. 3D CBCT axial view 3 mesial canals (arrows).

Fig. 6. Axial view 3 mesial canals.

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Fig. 7. Postoperative 2D periapical x-ray 3 mesial canals.

CALCIFICATIONS
Case #3: Maxillary Left Central Incisor Diagnosis—Pulpal Necrosis/Symptomatic Apical
Periodontitis
Canal obliteration may represent dystrophic calcifications (DC, calcification of degen-
erating or necrotic tissue pulp stones23) or calcific metamorphosis (CM, A process of
mineralization after trauma24) (Figs. 8–11). The mechanism for dentin deposition in CM
has been debated by the profession and is still unclear.25,26 It has been suggested that
the severity of the injury may be related to the rate of deposition.27 The predominance

Fig. 8. Preoperative 2D periapical x-ray, arrow points to calcified root canal.

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Fig. 9. 3D CBCT sagittal view, arrow pointing to visible canal.

of literature suggests that despite the appearance of CM on a 2D radiograph, a narrow

pulp canal space persists (see Figs. 9 and 10).26,28–30 With the development of CBCT,
pretreatment identification and location of this narrow pulp space can facilitate
minimally invasive treatment.

Fig. 10. Preoperative 3D CBCT axial view, arrow pointing to visible canal.
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Fig. 11. Postoperative 2D periapical x-ray minimally invasive treatment.

LATERAL CANALS
Case #4: Maxillary Left Central Incisor Diagnosis—Pulpal Necrosis/Symptomatic Apical
Periodontitis
Treatment of lateral canals requires pretreatment knowledge of their presence and
location (Figs. 12–15).31 2D radiology does not provide adequate information to

Fig. 12. Preoperative 2D periapical x-ray.

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Fig. 13. Preoperative 3D CBCT coronal view, arrow pointing to lateral canal exiting into
lateral radicular defect.

Fig. 14. 3D CBCT sagittal view provides accurate measurement from apex to lateral canal
(distance between arrows).
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Fig. 15. Postoperative 2D periapical x-ray, guttapercha cone in lateral canal.

predictably locate and treat this entity.32,33 Successful endodontic treatment depends
on the adequate debridement of bacteria from all spaces.31 CBCT technology assists
the practitioner with identifying the specific location of lateral canals (see Figs. 13 and
14). Overcoming the obstacle of identifying and locating lateral canals enhances the
ability to treat these difficult cases (see Fig. 15).34

BONE MORPHOLOGY IDENTIFIABLE ON CBCT

Fenestration Case #5
Identification of a fenestration can assist in planning apical surgery (Figs. 16–18).35
CBCT offers the opportunity to accurately evaluate an area of apical periodontitis

Fig. 16. 3D CBCT preoperative sagittal view—isolating buccal plate demonstrating fenestra-
tion (arrow pointing to fenestration of Buccal Bone).
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Fig. 17. 3D CBCT preoperative reconstructed view buccal plate demonstrating fenestration
(arrow pointing to fenestration of buccal bone).

Fig. 18. Apical operative view, demonstrating fenestration observed after flap reflection
(arrow pointing to fenestration of buccal bone).

for size, volume, and location before surgery.36 Some studies find no value in apical
grafting, while others advocate that the need for grafting is based on the volume of
the space to be grafted.37 These studies suggest that larger lesions may not heal suc-
cessfully from apical surgery without grafting, due to a lack of clot stability.38 CBCT
can be used to determine the volume of the apical periodontitis lesion. Future research
may be able to identify the specific volumetric limits for clot stability and graft usage as
opposed to the linear measurement currently used.

Dehiscence Case #6
Maxillary left second bicuspid—diagnosis: previously treated root canal/symptomatic
apical periodontitis. In case #6 (Figs. 19–22), despite a careful and comprehensive ex-
amination and periodontal probing, a vertical root fracture was clinically undetectable.
The etiology for endodontic failure was ultimately identified with the use of a CBCT.
Isolating the buccal plate defect on a coronal plane view assisted to identify the boney
dehiscence (see Fig. 21). In this case, the vertical fracture was verified during the sur-
gical exposure (see Fig. 22). Vertical fractures and cracks may not be visible on 3D
 CBCT Updated Technology for Endodontic Diagnosis 533

Fig. 19. Preoperative 2D periapical x-ray #13.

Fig. 20. 3D CBCT axial view (arrow pointing to buccal bone defect over vertical fracture).

Fig. 21. 3D CBCT sagittal view (arrows pointing to buccal bone dehiscence). The fracture
may not be visible on CBCT; look for the adjacent bone loss (arrows).
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Fig. 22. Surgical exposure of fracture and dehiscence (arrows). The fracture may not be
visible on CBCT; look for the adjacent bone loss (arrows).

images. The Nyquest Theorem identifies the limitation of an image’s ability to identify a
crack or fracture defect to equal twice the voxel size used to scan the object.39

IDENTIFYING CYSTS

A radicular cyst is a common odontogenic lesion of inflammatory origin. The ability to

distinguish a cyst from a granuloma has been studied over the years.40–45 Various
studies have suggested that the presence of an opaque lamina provides evidence
of a cyst. A study by Ricucci and colleagues46 refutes this theory. In support, one
only needs to return to the findings of Seltzer, Bender, Bhaskar47 and more recently
by Lalonde,40 to see that cysts, granulomas, and abscess all have a similar appear-
ance on 2D radiographs. Conflicting studies have been published debating CBCT’s
effectiveness to distinguish cysts from granulomas.48 In the following examples, one
observes the lumen of the cyst42 as detected on CBCT (Figs. 23 and 24) but not visible

Fig. 23. 3D CBCT coronal view of apical periodontitis #5 with cystic lumen (arrow pointing to
black cystic lumen within gray apical defect).
 CBCT Updated Technology for Endodontic Diagnosis 535

Fig. 24. 3D CBCT sagittal view of apical periodontitis #5 with cystic lumen (arrow pointing to
black cystic lumen within gray apical defect).

Fig. 25. Three views of an incisive canal cyst. (Data from Faitaroni LA, Bueno MR, Carvalhosa AA,
et al. Differential diagnosis of apical periodontitis and nasopalatine duct cyst. J Endod
2011;37(3):403–10.)

on preoperative 2D image (Fig. 26). The question remains, however; if the lumen is not
visible, is it a granuloma? Further research is needed to clarify this issue.
Case #7 Diagnosis: incisive canal cyst (Fig. 25).
Case #8 Maxillary right first bicuspid—diagnosis: pulpal necrosis/asymptomatic
apical periodontitis radicular cyst (see Figs. 23, 24 and 26).

Fig. 26. Preoperative 2D image of apical periodontitis #5.

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Endodontic Recall
Endodontic healing has traditionally been verified clinically and radiographically. The
AAE 2005 definitions are described in Box 1.

Box 1
Definitions of endodontic outcomes

Healed—functional, asymptomatic teeth with no or minimal radiographic

periradicularpathosis
Nonhealed—nonfunctional, symptomatic teeth with or without radiographic
periradicularpathosis
Healing—teeth with radiographic periradicularpathosis, which are asymptomatic and
functional, or teeth with or without radiographic periradicularpathosis, which are
symptomatic but whose intended function is not altered
Functional—a treated tooth or root that is serving its intended purpose in the dentition

Modified from Ingles’s Endodontics 6, chapter 32. Friedman S, editor. Treatment outcome: The
potential for healing and retained function. p. 1162–232.

The outcome of endodontically treated teeth is heavily weighted on the observation

of radiographic healing. The low predictive value49 of 2D radiography limits its useful-
ness for evaluation of repair. 3D imaging expands the function of the recall examina-
tion to include all periradicular tissues (cortical and medullary bone). The subsequent
examples apply current CBCT technology to discover the true status of all periradic-
ular tissues.50 2D radiographs may indicate buccal or lingual plate healing but can
mask the periradicular status. As noted by Orstavik, healing may take 1 to 4 years.45

Case #9: Healing—Diagnosis: Previously Treated Root Canal/Asymptomatic Apical

Periodontitis
Nonsurgical retreatment was completed in 2 visits with Ca(OH)2 used as intravisit
medicament (Figs. 27 and 28). Patient returned for a 1-year routine recall (Fig. 29),
asymptomatic. 2D radiographic examination revealed healed apex, while the 3D
radiograph (Fig. 30) exhibited possible reduction is size of asymptomatic apical peri-
odontitis when compared with 3D preoperative images (see Fig. 28).

Fig. 27. Pre-operative 2D periapical x-ray.

 CBCT Updated Technology for Endodontic Diagnosis 537

Fig. 28. Pre-operative 3D.

Fig. 29. 1 year recall 2D periapical x-ray.

Fig. 30. 1 year recall 3D.

Case #10: Healed—Diagnosis: Previous Root Canal Treatment (Missed Mesiobuccal)/

Symptomatic Apical Periodontitis
Nonsurgical retreatment was completed in 2 visits (Figs. 31 and 32), with Ca(OH)2
used as intravisit medicament. The patient returned 3 years after retreatment with
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Fig. 31. Preoperative 2D periapical x-ray, 7/27/09.

Fig. 32. Postoperative 2D periapical x-ray, 8/27/09.

continuous evidence of apical periodontitis on 2D radiograph. Surgical intervention

(apicoectomy) was performed. One year and 18 months later, 2D (Figs. 33 and 34)
and 3D screen shots exhibited healing of periradicular tissues.

Fig. 33. 1 year recall 2D periapical x-ray apicoectomy.

 CBCT Updated Technology for Endodontic Diagnosis 539

Fig. 34. 3D CBCT coronal view; note healed buccal plate and medullary bone (arrows).

TRAUMA

Traumatic injuries to the dentition result in 1 of 3 outcomes. First, teeth may regain vital
responses to tests due to revascularization. Second, teeth may remain nonresponsive
to vitality tests due to aseptic necrosis (without apical periodontitis), or third, teeth may
become infected and develop acute or chronic apical periodontitis (Figs. 35–37).51,52
CBCT can help the clinician make an earlier diagnosis. Generally necrotic changes are
evident within 3 months of the trauma.53,54 Early intervention of endodontic treatment
based on clinical and radiographic evidence can help avoid tooth loss due to resorption.55

Fig. 35. 3D CBCT coronal view—fracture of anterior maxilla observed superior to canine and
lateral incisor (arrows).
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Fig. 36. 3D CBCT sagittal view of horizontal root fracture (arrows).

Fig. 37. 3D CBCT rendering of horizontal root fracture (arrow).

Osseous Trauma: Case #11

A 45-year-old woman was hit in the face by a bus mirror and sustained a maxillary
fracture, avulsions and luxations of multiple teeth (see Figs. 35–37). The CBCT was
used to identify components of the maxillary fracture’s location and morphology, ridge
defect height and width, and imaging of the temporomandibular joints.56,57

CONCLUSIONS

The previous examples identify the value of CBCT for Endodontics. Narrow field
of view CBCT facilitates diagnosis, treatment and outcome assessment while
adhering to ALARA principles. Additional applications for this technology can be
 CBCT Updated Technology for Endodontic Diagnosis 541

expected within the Endodontic field as a result of the explosion of research in the
imaging field.

REFERENCES

1. Burrill DY. Pulp testing by determination of fusion frequency. J Dent Res 1962;
41:437–45.
2. Gazelius B, Olgart L, Edwall B, et al. Non-invasive recording of blood flow in
human dental pulp. Endod Dent Traumatol 1986;2(5):219–21.
3. Ruprecht A. When was the first dental radiograph taken on human? In: Sci-
ence, Inventions The first dental radiograph was taken in January 1896 by
Otto Walkhoff, D.D.S., M.D., in Brunswick, Germany, a few days after Wilhelm
Roentgen published about his discovery of x-rays. Walkhoff placed a small
photographic plate wrapped in rubberdam in his mouth and subjected himself
to 25 minutes of x-ray exposure. Exposure times today are in the range of 0.01–
0.03 seconds. The Journal of the American Dental Association 2008;139:
55–65.
4. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental
lesions in bone: I. 1961. J Endod 2003;29(11):702–6 [discussion: 701].
5. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental
lesions in bone: II. 1961. J Endod 2003;29(11):707–12 [discussion: 701].
6. Durack C, Patel S. Cone beam computed tomography in endodontics. Braz
Dent J 2012;23(3):179–91.
7. Brynolf I. Radiography of the periapical region as a diagnostic aid. I. Diagnosis
of marginal changes. Dent Radiogr Photogr 1978;51(2):21–39.
8. Goldman M, Pearson AH, Darzenta N. Reliability of radiographic interpretations.
Oral Surg Oral Med Oral Pathol 1974;38(2):287–93.
9. Goldman M, Pearson AH, Darzenta N. Endodontic success–who’s reading the
radiograph? Oral Surg Oral Med Oral Pathol 1972;33(3):432–7.
10. Valachovic RW, Douglass CW, Berkey CS, et al. Examiner reliability in dental
radiography. J Dent Res 1986;65(3):432–6.
11. Estrela C, Bueno MR, Leles CR, et al. Accuracy of cone beam computed tomog-
raphy and panoramic and periapical radiography for detection of apical peri-
odontitis. J Endod 2008;34(3):273–9.
12. Orstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for
radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;
2(1):20–34.
13. Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin
North Am 2008;52(4):707–30.
14. Mozzo P, Procacci C, Tacconi A, et al. A new volumetric CT machine for dental
imaging based on the cone-beam technique: preliminary results. Eur Radiol
1998;8(9):1558–64.
15. Farman AG, Scarfe WC. Development of imaging selection criteria and proce-
dures should precede cephalometric assessment with cone-beam computed
tomography. Am J Orthod Dentofacial Orthop 2006;130(2):257–65.
16. Ha, Dan-Linh. Accuracy of limited field cone beam computed tomography in the
detection of buccal cortical plate perforations due to periapical lesions. 2013.
Available at: http://hdl.handle.net/10156/4225. Accessed May 9, 2013.
17. Hashimoto K, Arai Y, Iwai K, et al. A comparison of a new limited cone beam
computed tomography machine for dental use with a multidetector row helical
CT machine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(3):371–7.
542 Todd

18. American Association of Endodontists. Endodontics colleagues for excellences:

cone beam-computed tomography. Chicago: American Association of Endodon-
tists; 2011.
19. Patel S, Dawood A, Pitt Ford T, et al. The potential applications of cone beam
computed tomography in the management of endodontic problems. Int Endod
J 2007;40:818–30.
20. Cotton TP, Geisler TM, Holden DT, et al. Endodontic applications of cone beam
volumetric tomography. J Endod 2007;33:1121–32.
21. Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2005;100:395–7.
22. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth
can fail. Int Endod J 2001;34:1–10.
23. Wakabayashi H, Horikawa M, Funato A, et al. Bio-microscopical observation of
dystrophic calcification induced by calcium hydroxide. Endod Dent Traumatol
1993;9(4):165–70.
24. Amir FA, Gutmann JL, Witherspoon DE. Calcific metamorphosis: a challenge in
endodontic diagnosis and treatment. Quintessence Int 2001;32(6):447–55.
25. Andreasen J. Luxation of permanent teeth due to trauma. Scand J Dent Res
1970;78:273–86.
26. Torneck C. The clinical significance and management of calcific pulp oblitera-
tion. Alpha Omegan 1990;83:50–4.
27. Ten Cate AR. Oral histology: development, structure, and function. 5th edition.
St Louis (MO): Mosby; 1998.
28. Holcomb J, Gregory W. Calcific metamorphosis of the pulp: its incidence and
treatment. Oral Surg Oral Med Oral Pathol 1967;24:825–30.
29. Schindler WG, Gullickson DC. Rationale for the management of calcific meta-
morphosis secondary to traumatic injuries. J Endod 1988;14:408–12.
30. Smith J. Calcific metamorphosis: a treatment dilemma. Oral Surg Oral Med Oral
Pathol 1982;54:441–4.
31. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifica-
tions in response to pathologic conditions and treatment procedures. J Endod
2010;36(1):1–15.
32. De Deus QD. Frequency, location, and direction of the lateral, secondary, and
accessory canals. J Endod 1975;1:361–6.
33. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral
Med Oral Pathol 1984;58:589–99.
34. Weine FS. The enigma of the lateral canal. Dent Clin North Am 1984;28:833–52.
35. Scarfe WC, Levin MD, Gane D, et al. The use of cone beam computed tomog-
raphy in endodontics. Int J Dent 2009;2009:634567.
36. Suebnukarn S, Rhienmora P, Haddawy P. The use of cone-beam computed
tomography and virtual reality simulation for pre-surgical practice in endodontic
microsurgery. Int Endod J 2012;45(7):627–32.
37. Sreedevi PV, Varghese NO, Varugheese JM. Prognosis of periapical surgery
using bonegrafts: a clinical study. J Conserv Dent 2011;14(1):68–72.
38. Dudek D, So1tykiewicz K, Helewski K, et al. Treatment of a mandibular cyst with
synthetic bone graft substitute. Implants 1 2013;34–36.
39. Wang P, Yan XB, Lui DG, et al. Detection of dental root fractures by using cone-
beam computed tomography. Dentomaxillofac Radiol 2011;40:290–8.
40. Lalonde ER, Luebke RG. The frequency and distribution of periapical cysts and
granulomas: an evaluation of 800 specimens. Oral Surg Oral Med Oral Pathol
1968;25(6):861–8.
 CBCT Updated Technology for Endodontic Diagnosis 543

41. Kuc I, Peters E, Pan J. Comparison of clinical and histologic diagnoses in periap-
ical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89(3):333–7.
42. Rosenberg PA, Frisbie J, Lee J, et al. Evaluation of pathologists (histopathology)
and radiologists (cone beam computed tomography) differentiating radicular
cysts from granulomas. J Endod 2010;36(3):423–8.
43. Shrout MK, Hall JM, Hildebolt CE. Differentiation of periapical granulomas and
radicular cysts by digital radiometric analysis. Oral Surg Oral Med Oral Pathol
1993;76(3):356–61.
44. White SC, Sapp JP, Seto BG, et al. Absence of radiometric differentiation
between periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol
1994;78(5):650–4.
45. Orstavik D. Time-course and risk analyses of the development and healing of
chronic apical periodontitis in man. Int Endod J 1996;29(3):150–5.
46. Ricucci D, Mannocci F, Ford TR. A study of periapical lesions correlating the
presence of a radiopaque lamina with histological findings. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2006;101(3):389–94.
47. Bhaskar SN. Periapical lesions—types, incidence, and clinical features. Oral
Surg Oral Med Oral Pathol 1966;21(5):657–71.
48. Trope M, Pettigrew J, Petras J, et al. Differentiation of radicular cyst and granu-
lomas using computerized tomography. Endod Dent Traumatol 1989;5(2):
69–72.
49. Peters CI, Peters OA. Cone beam computed tomography and other imaging
techniques in the determination of periapical healing. Endod Top 2012;26(1):
57–75.
50. Khetarpal A, Chaudhary S, Sahai S, et al. Radiological assessment of periapical
healing using the cone beam computed tomography periapical index: case
report. IOSR Journal of Dental and Medical Sciences 2013;9(5):46–51.
51. Jacobsen I. Criteria for diagnosis of pulp necrosis in traumatized permanent in-
cisors. Scand J Dent Res 1980;88(4):306–12.
52. Sundqvist G. Bacteriological studies of necrotic dental pulps. Department of
Oral Microbiology, University of Umeå; 1976. p. 94.
53. Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth — the
development of pulp necrosis. Endod Dent Traumatol 1985;1:207–20.
54. Jacobsen I, Kerekes K. Diagnosis and treatment of pulp necrosis in permanent
anterior teeth with root fracture. Scand J Dent Res 1980;88(5):370–6.
55. Andreasen JO, Andreasen FM. Root resorption following traumatic dental
injuries. Proc Finn Dent Soc 1992;88(Suppl 1):95–114.
56. Palomo L, Palomo JM. Cone beam CT for diagnosis and treatment planning in
trauma cases. Dent Clin North Am 2009;53:717–27.
_
57. Ilgüy D, _Ilgüy M, Fisekcioglu E, et al. Detection of jaw and root fractures using
cone beam computed tomography: a case report. Dentomaxillofac Radiol
2009;38:169–73.