sâmbătă, 6 septembrie 2014

Ghidurile Europene pentru CBCT - partea a III - a



4: JUSTIFICATION AND REFERRAL CRITERIA

As with any X-ray exposure, CBCT entails a risk to the patient. It is essential that any X-ray examination should show a net potential benefit to the patient, weighing the total potential diagnostic benefits it produces against the individual detriment that the exposure might cause. The efficacy, benefits and risk of available alternative techniques having the same objective but involving less (or no) exposure to X-rays should be taken into account. A record of the justification process must be made in the patient‟s clinical records.

All CBCT examinations must be justified on an individual basis by demonstrating that the potential benefits to the patients outweigh the potential risks. CBCT examinations should potentially add new information to aid the patient‟s management. A record of the Justification process must be maintained for each patient
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In order that the justification process can be carried out, it is essential that selection of dental CBCT is based on the individual patient‟s history and a clinical examination. The “routine” use of dental CBCT on patients based on a generalised approach rather than individual prescription is unacceptable. A “routine” (or “screening”) examination is defined as one in which a radiograph is taken regardless of the presence or absence of clinical signs and symptoms.

CBCT should not be selected unless a history and clinical examination have been performed. “Routine” or “screening” imaging is unacceptable practice
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Societal efficacy
Choosing dental CBCT for a patient should also be based upon consideration of the prevalence of diseases, their rates of progression and the diagnostic accuracy of CBCT, compared with traditional techniques, for the application in question.

“Diagnostic efficacy” of any medical imaging modality encompasses a spectrum of performance measures. The hierarchical model presented by Fryback & Thornbury (1991) conceptualised this into six levels of efficacy:
·         Technical efficacy
·         Diagnostic accuracy efficacy
·         Diagnostic thinking efficacy
·         Therapeutic efficacy
·         Patient outcome efficacy
·         Societal efficacy 
In reviewing the literature on dental CBCT, the Panel recognised that understanding of its diagnostic efficacy was largely limited to the first two of these levels. Even for these, knowledge is incomplete. Only a few publications were identified which address higher levels of diagnostic efficacy. This means that the development of guidelines with high evidence grades was precluded. It also highlights the need for clinical trials which will provide information on “higher level” efficacies, notably Patient Outcome Efficacy (e.g. the proportion of patients improved in a clinical therapeutic procedure with the use of CBCT compared with the proportion improved without CBCT).

Consulting guidelines facilitates the process of selecting radiographs. Such guidelines, called “referral criteria” or “selection criteria” exist for both medical and traditional dental imaging. Radiographic referral criteria have been defined as:

descriptions of clinical conditions derived from patient signs, symptoms and history that identify patients who are likely to benefit from a particular radiographic technique".

As with any guideline, these are not intended to be rigid constraints on clinical practice, but a concept of good practice against which the needs of the individual patient can be considered. The term “referral criteria” is appropriate for medical practitioners, where radiography is usually arranged by referral to a specialist in radiology. With CBCT, this situation may also apply, with the dentist referring to a hospital department or to a dentist-colleague. When acting as a referrer, the dentist should ensure that adequate clinical information about the patient is provided to the person taking responsibility for the exposure.

When referring a patient for a CBCT examination, the referring dentist must supply sufficient clinical information (results of a history and examination) to allow the CBCT Practitioner to perform the Justification process
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In the Provisional Guideline document (SEDENTEXCT 2009), referral criteria were devised for a range of uses of dental CBCT that became apparent during the course of the systematic review, with priority given to paediatric uses. In the interim period, before publication of this current document, some European national organizations have presented indications for the use of dental CBCT (Haute Autorité de Santé, 2009; Leitlinie der DGZMK, 2009; Advies van de Hoge Gezondheidsraad, 2011); due account has been taken of these.

These studies encompassed a good range of dental CBCT equipment manufacturers and models. The results suggest that differences between CBCT-derived measurements and the reference standard appear to be small and are unlikely to be clinically significant. Laboratory studies do not, however, take account of minor patient movements which, while difficult to perceive in terms of poorer image quality, might contribute to added discrepancy between the image dimensions and reality. The methodologies and the objectives of these studies were usually very different, so that it remains difficult to make valid comparisons between equipment. Clearly, as new equipment is introduced, these kinds of efficacy studies should continue to be performed. It would, however, be valuable if a standard battery of tests using a commercially available phantom were prospectively adopted so that comparisons of equipment could be most usefully made.

4.1.1 Dimensional accuracy of CBCT

One aspect of imaging which is important to all aspects of clinical use of dental CBCT is dimensional (geometric) accuracy. Clearly, however, this is of particular importance in certain applications, such as implantology and orthodontics where accurate quantitative information is required. There are numerous publications on linear accuracy of dental CBCT and some dealing with angular measurements. Although these fell outside the strict inclusion criteria of the systematic review of diagnostic accuracy, the Panel conducted a separate review process for these studies. While the search methodology for this element of the review may have omitted some research of relevance, the Panel identified 50 publications where the primary focus of studies was judged to be aspects of measurement accuracy (Agbaje et al 2007; Al-Ekrish et al 2011; Al-Rawi et al 2010; Ballrick et al 2008; Baumgaertel et al 2009; Berco et al 2009; Brown et al 2009; Cattaneo et al 2008; Cevidanes et al 2005; Chen et al 2008; Damstra et al 2010; Eggers et al 2008; Eggers et al 2009; Fatemitabar et al 2010; Fourie et al 2010; Grauer et al 2010; Gribel et al. 2011; Hassan et al. 2009; Hilgers et al 2005; Kamburoğlu et al. 2010; Kobayashi et al 2004; Kumar et al 2007; Kumar et al 2008; Lagravère et al. 2008; Lamichane et al 2009; Lascala et al 2004; Liu et al 2010; Loubele et al 2008; Ludlow et al 2007; Luk et al 2011; Lund et al 2009; Marmulla et al 2005; Mischkowski et al 2007; Moerenhout et al 2009; Moreira et al. 2009; Moshiri et al 2007; Naitoh et al 2009; Peck et al 2006; Periago et al 2008; Pinsky et al 2006; Razavi et al 2010; Sakabe et al 2007; Sherrard et al 2010; Stratemann et al 2008; Suomalainen et al 2008; Tsutsumi et al 2011; Van Assche et al 2007; Van Elslande et al 2010; van Vlijmen et al 2009; Veyre-Goulet et al 2008).

4.1.2 References

Advies van de Hoge Gezondheidsraad nr. 8705. Dentale Cone Beam Computed Tomography. Brussel: Hoge Gezondheidsraad, 2011. www.hgr-css.be

Agbaje JO, Jacobs R, Maes F, Michiels K, van Steenberghe D.
Volumetric analysis of extraction sockets using cone beam computed tomography: a pilot study on ex vivo jaw bone. J Clin Periodontol 2007; 34: 985-990.

Al-Ekrish AA, Ekram M. A comparative study of the accuracy and reliability of multidetector computed tomography and cone beam computed tomography in the assessment of dental implant site dimensions. Dentomaxillofac Radiol. 2011; 40: 67-75.
Al-Rawi B, Hassan B, Vandenberge B, Jacobs R. Accuracy assessment of three-dimensional surface reconstructions of teeth from cone beam computed tomography scans. J Oral Rehabil. 2010; 37: 352-358.

Ballrick JW, Palomo JM, Ruch E, Amberman BD, Hans MG. Image distortion and spatial resolution of a commercially available cone-beam computed tomography machine. Am J Orthod Dentofacial Orthop 2008; 134: 573-582.

Baumgaertel S, Palomo JM, Palomo L, Hans MG. Reliability and accuracy of cone-beam computed tomography dental measurements. Am J Orthod Dentofacial Orthop 2009; 136: 19-25; discussion 25-28.

Berco M, Rigali PH Jr, Miner RM, DeLuca S, Anderson NK, Will LA. Accuracy and reliability of linear cephalometric measurements from cone-beam computed tomography scans of a dry human skull. Am J Orthod Dentofacial Orthop. 2009; 136: 17.e1-9; discussion 17-8.

Brown AA, Scarfe WC, Scheetz JP, Silveira AM, Farman AG. Linear accuracy of cone beam CT derived 3D images. Angle Orthod. 2009 Jan;79(1):150-7.

Cattaneo PM, Bloch CB, Calmar D, Hjortshoj M, Melsen B. Comparison between conventional and cone-beam computed tomography-generated cephalograms. Am J Orthod Dentofacial Orthop 2008; 134: 798-802.

Cevidanes LHS, Bailey LJ, Tucker GR, Jr., Styner MA, Mol A, Phillips CL, Proffit WR, Turvey T. Superimposition of 3D cone-beam CT models of orthognathic surgery patients. Dentomaxillofac Radiol 2005; 34: 369-375.

Chen L-C, Lundgren T, Hallstrom H, Cherel F. Comparison of different methods of assessing alveolar ridge dimensions prior to dental implant placement. J Periodontol 2008; 79: 401-405.

Damstra J, Fourie Z, Huddleston Slater JJR, Ren Y. Accuracy of linear measurements from cone-beam computed tomography-derived surface models of different voxel sizes. Am J Orthod Dentofacial Orthop 2010; 137: 16.e1-6; discussion 16-17.

Eggers G, Klein J, Welzel T, Muhling J. Geometric accuracy of digital volume tomography and conventional computed tomography. Br J Oral Maxillofac Surg 2008; 46: 639-644.

Eggers G, Senoo H, Kane G, Muhling J. The accuracy of image guided surgery based on cone beam computer tomography image data. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: e41-48.

Fatemitabar SA, Nikgoo A. Multichannel computed tomography versus cone-beam computed tomography: linear accuracy of in vitro measurements of the maxilla for implant placement. Int J Oral Maxillofac Implants. 2010 May-Jun;25(3):499-505.

Fourie Z, Damstra J, Gerrits PO, Ren Y. Evaluation of anthropometric accuracy and reliability using different three-dimensional scanning systems. Forensic Sci Int 2010; Oct 14. [Epub ahead of print]

Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11: 88-94.

Grauer D, Cevidanes LSH, Styner MA, Heulfe I, Harmon ET, Zhu H, Proffit WR. Accuracy and landmark error calculation using cone-beam computed tomography-generated cephalograms. Angle Orthod 2010; 80: 286-294.

Gribel BF, Gribel MN, Manzi FR, Brooks SL, McNamara JA Jr.
Accuracy and reliability of craniometric measurements on lateral cephalometry and 3D measurements on CBCT scans. Angle Orthod. 2011; 81: 3-10.

Haute Autorité de Santé. Tomographie Volumique a Faisceau Conique de la Face (Cone Beam Computerized Tomography). Rapport d‟évaluation Technologique. Service évaluation des actes professionnels. Saint-Denis La Plaine: Haute Autorité de Santé, 2009. http://www.has-sante.fr

Hassan B, van der Stelt P, Sanderink G. Accuracy of three-dimensional measurements obtained from cone beam computed tomography surface-rendered images for cephalometric analysis: influence of patient scanning position. Eur J Orthod. 2009 Apr;31(2):129-34.

Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear temporomandibular joint measurements with cone beam computed tomography and digital cephalometric radiography. Am J Orthod Dentofacial Orthop 2005; 128: 803-811.

Kamburoğlu K, Kolsuz E, Kurt H, Kılıç C, Ozen T, Semra Paksoy C.
Accuracy of CBCT Measurements of a Human Skull. J Digit Imaging. 2010 Sep 21. [Epub ahead of print]

Kobayashi K, Shimoda S, Nakagawa Y, Yamamoto A. Accuracy in measurement of distance using limited cone-beam computerized tomography. Int J Oral Maxillofac Implants 2004; 19: 228-231.

Kumar V, Ludlow J, Soares Cevidanes LH, Mol A. In vivo comparison of conventional and cone beam CT synthesized cephalograms. Angle Orthod 2008; 78: 873-879.

Kumar V, Ludlow JB, Mol A, Cevidanes L. Comparison of conventional and cone beam CT synthesized cephalograms. Dentomaxillofacl Radiol 2007; 36: 263-269.

Lagravère MO, Carey J, Toogood RW, Major PW. Three-dimensional accuracy of measurements made with software on cone-beam computed tomography images. Am J Orthod Dentofacial Orthop. 2008; 134: 112-116.

Lamichane M, Anderson NK, Rigali PH, Seldin EB, Will LA. Accuracy of reconstructed images from cone-beam computed tomography scans. Am J Orthod Dentofacial Orthop. 2009; 136: 156.e1-6; discussion 156-7.

Lascala CA, Panella J, Marques MM. Analysis of the accuracy of linear measurements obtained by cone beam computed tomography (CBCT-NewTom). Dentomaxillofac Radiol 2004; 33: 291-294.

Leitlinie der DGZMK. Dentale Volumentomographie (DVT) - S1 Empfehlung. Deutsche Zahnärztliche Zeitschrift 64, 2009: 490 - 496.

Liu Y, Olszewski R, Alexandroni ES, Enciso R, Xu T, Mah JK. The validity of in vivo tooth volume determinations from cone-beam computed tomography. Angle Orthod. 2010; 80:160-166.

Loubele M, Van Assche N, Carpentier K, Maes F, Jacobs R, van Steenberghe D, Suetens P. Comparative localized linear accuracy of small-field cone-beam CT and multislice CT for alveolar bone measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 512-518.

Ludlow JB, Laster WS, See M, Bailey LTJ, Hershey HG. Accuracy of measurements of mandibular anatomy in cone beam computed tomography images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103: 534-542.

Luk LC, Pow EH, Li TK, Chow TW. Comparison of ridge mapping and cone beam computed tomography for planning dental implant therapy. Int J Oral Maxillofac Implants 2011; 26: 70-74.

Lund H, Grondahl K, Grondahl HG. Accuracy and precision of linear measurements in cone beam computed tomography Accuitomo tomograms obtained with different reconstruction techniques. Dentomaxillofac Radiol 2009; 38: 379-386.

Marmulla R, Wortche R, Muhling J, Hassfeld S. Geometric accuracy of the NewTom 9000 Cone Beam CT. Dentomaxillofac Radiol 2005; 34: 28-31.

Mischkowski RA, Pulsfort R, Ritter L, Neugebauer J, Brochhagen HG, Keeve E, Zoller J E. Geometric accuracy of a newly developed cone-beam device for maxillofacial imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 551-559.

Moerenhout BA, Gelaude F, Swennen GR, Casselman JW, Van Der Sloten J, Mommaerts MY. Accuracy and repeatability of cone-beam computed tomography (CBCT) measurements used in the determination of facial indices in the laboratory setup. J Craniomaxillofac Surg. 2009; 37: 18-23.

Moreira CR, Sales MA, Lopes PM, Cavalcanti MG. Assessment of linear and angular measurements on three-dimensional cone-beam computed tomographic images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108: 430-436.

Moshiri M, Scarfe WC, Hilgers ML, Scheetz JP, Silveira AM, Farman AG. Accuracy of linear measurements from imaging plate and lateral cephalometric images derived from cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2007; 132: 550-560.

Naitoh M, Hirukawa A, Katsumata A, Ariji E. Evaluation of voxel values in mandibular cancellous bone: relationship between cone-beam computed tomography and multislice helical computed tomography. Clin Oral Implants Res 2009; 20: 503-506.
 
Peck JN, Conte GJ. Radiologic techniques using CBCT and 3-D treatment planning for implant placement. J Calif Dent Assoc 2006; 36: 287-290.

Periago DR, Scarfe WC, Moshiri M, Scheetz JP, Silveira AM, Farman AG. Kinear accuracy and reliability of cone beam CT derived 3-dimensional images constructed using an orthodontic volumetric rendering program. Angle Orthod 2008; 78: 387-395.

Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using cone-beam CT. Dentomaxillofac Radiol 2006; 35: 410-416.

Razavi T, Palmer RM, Davies J, Wilson R, Palmer PJ. Accuracy of measuring the cortical bone thickness adjacent to dental implants using cone beam computed tomography. Clin Oral Implants Res. 2010; 21: 718-725.

Sakabe J, Kuroki Y, Fujimaki S, Nakajima I, Honda K. Reproducibility and accuracy of measuring unerupted teeth using limited cone beam X-ray CT. Dentomaxillofac Radiol 2007; 36: 2-6.

SEDENTEXCT Guideline Development Panel. Radiation Protection: Cone Beam CT for Dental and Maxillofacial Radiology Provisional Guidelines 2009 (v 1.1 May 2009). www.sedentexct.eu

Sherrard JF, Rossouw PE, Benson BW, Carrillo R, Buschang PH. Accuracy and reliability of tooth and root lengths measured on cone-beam computed tomographs. Am J Orthod Dentofacial Orthop 2010; 137(4 Suppl): S100-8.

Stratemann SA, Huang JC, Maki K, Miller AJ, Hatcher DC. Comparison of cone beam computed tomography imaging with physical measures. Dentomaxillofac Radiol 2008; 37: 80-93.

Suomalainen A, Vehmas T, Kortesniemi M, Robinson S, Peltola J. Accuracy of linear measurements using dental cone beam and conventional multislice computed tomography. Dentomaxillofac Radiol 2008; 37: 10-17.

Tsutsumi K, Chikui T, Okamura K, Yoshiura K. Accuracy of linear measurement and the measurement limits of thin objects with cone beam computed tomography: effects of measurement directions and of phantom locations in the fields of view. Int J Oral Maxillofac Implants. 2011; 26: 91-100.

Van Assche N, van Steenberghe D, Guerrero ME, Hirsch E, Schutyser F, Quirynen M, Jacobs R. Accuracy of implant placement based on pre-surgical planning of three-dimensional cone-beam images: a pilot study. J Clin Periodontol 2007; 34: 816-821.

Van Elslande D, Heo G, Flores-Mir C, Carey J, Major PW. Accuracy of mesiodistal root angulation projected by cone-beam computed tomographic panoramic-like images. Am J Orthod Dentofacial Orthop. 2010; 137 (4 Suppl):S94-9.

van Vlijmen OJC, Berge SJ, Swennen GRJ, Bronkhorst EM, Katsaros C, Kuijpers-Jagtman AM (2009). Comparison of cephalometric radiographs obtained from cone-beam computed tomography scans and conventional radiographs. J Oral Maxillofac Surg 2009; 67: 92-97.

Veyre-Goulet S, Fortin T, Thierry A. Accuracy of linear measurement provided by cone beam computed tomography to assess bone quantity in the posterior maxilla: a human cadaver study. Clin Implant Dent Relat Res 2008; 10: 226-230.

4.2: The developing dentition

Many children seek orthodontic treatment. For children in the mixed dentition stage, where there are abnormalities in eruption pattern, tooth position or signs of crowding, radiographs may be required to determine the presence, absence, position and condition of teeth. Most orthodontic appliance treatment takes place at around 12-13 years of age, at which stage radiographs may be necessary to confirm the presence, absence, position and condition of teeth as an aid to treatment planning.

Justification of X-ray examinations in children is especially important because of the higher risks associated with exposure in children (see section 2.4). Traditional radiological examination of children undergoing orthodontic assessment relies on a panoramic radiograph, supplemented by a lateral cephalometric radiograph in specific circumstances. Intraoral radiographs are also used according to patient-specific needs. In recent years, however, the availability of CBCT has led to this technique being used by some clinicians as a means of radiological examination. The recent review of Kapila et al (2011) provides a useful summary of the current status of CBCT in orthodontics.

For assessment of facial bone shape, position and inter-relationships, there must be a high accuracy of measurements made with CBCT. Since the previous review, a large number of studies have been published on dimensional accuracy (see Section 4.1.1), many using direct measurement of skeletal material as a reference standard. Broadly speaking, these can be summarised as demonstrating that dental CBCT has a high accuracy for measurements, with any differences between image-derived measurements and the reference standard being so small as to be clinically irrelevant.

The applications of dental CBCT in assessment of the developing dentition for orthodontics will be considered under two broad headings: localised applications to answer a specific question and generalised application for examination of the entire dento-facial region.

4.2.1 Localised applications of CBCT for the developing dentition

Unerupted tooth localisation
A frequent application of CBCT is for assessment of the position of an unerupted tooth, particularly where the tooth is impacted. In these cases, an integral aspect of the assessment is often the accurate identification of any resorption of adjacent teeth. Such a situation is most often seen where maxillary canines are ectopic and incisor roots are suspected of having undergone resorption (Walker et al 2005). Traditional radiological assessment relies upon the use of parallax movement between images taken with different perspectives. In some specialised centres, MSCT has been used for this purpose, so some studies have concentrated on this comparison of performance.

Teeth are relatively large objects, having good contrast with the surrounding bone. It is obvious that a three-dimensional imaging technique with acceptable measurement accuracy and little distortion will identify position of teeth with high diagnostic accuracy. A recent systematic review (Guerrero et al, 2011) identified only four studies in which diagnostic accuracy had been determined for CBCT in relation to impacted teeth against a reference standard, all of which related to mandibular third molars (reviewed in Section 4.1.1). Our systematic review also did not identify any diagnostic accuracy studies for inclusion relevant to orthodontics.

In the previous SEDENTEXCT review in 2009, the literature on this use of CBCT was dominated by case reports and series (see Table 4.1) and those of Liu et al (2007, 2008) were highlighted in view of their scale. On this occasion, however, three studies (Haney et al 2010; Botticelli et al 2010; Katheria et al 2010) were identified by the Panel which measured aspects of “Diagnostic Thinking Efficacy” and “Therapeutic Efficacy” (Fryback & Thornbury 1991). Haney et al (2010) in a clinical study of impacted maxillary canine teeth, showed that there were differences in diagnosis of tooth position between those made using conventional radiography and those made using CBCT, although this was only in a minority of observations. There were larger differences in treatment plans when the two imaging methods were compared, while confidence in diagnosis and treatment plans was greater when CBCT was used. Botticelli et al (2010) showed that the understanding of canine position was different when CBCT was used compared with conventional imaging and that, in a minority of cases, treatment decisions were different. Similar findings for defining canine and supernumerary tooth position were reported by Katheria et al (2010), while observers in their study scored a significantly higher proportion of CBCT examinations as “very useful” in treatment planning than for conventional radiographic examinations. While there is a message here that the availability of CBCT changes diagnosis and treatment plans for a proportion of cases, it must be remembered that this may not be translated into better outcomes for patients.

Despite the expected advantage of CBCT in tooth localisation, it is important to consider the impact upon management of patients, the increased radiation dose and the likely higher cost of CBCT examinations. Conventional radiography has served dentists and specialist orthodontists well over many years, and the Panel concluded that there is a need for research demonstrating changed (and improved) outcomes for patients before widespread use of CBCT for this purpose could be considered. An exception to this would be where current practice is to use MSCT for localisation of unerupted teeth (Alqerban et al, 2009a). In such cases, CBCT is likely to be preferred over MSCT if dose is lower. In any case, radiological examination of maxillary canines is not usually necessary before 10 years of age.

For the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth) where the current imaging method of choice is MSCT, CBCT may be preferred because of reduced
radiation dose
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External resorption in relation to unerupted teeth
Assessment of impacted tooth position also involves assessment of the presence or absence of resorption in adjacent teeth. This application of CBCT has been considered in several case series and non-systematic reviews (Table 4.1). The review of Alqerban et al (2009a) considered this aspect in detail for the maxillary canine.

The Panel identified one relevant study for formal appraisal in the systematic review of diagnostic accuracy (Alqerban et al 2009b) in which accuracy of diagnosis of simulated resorption cavities in a skull was measured for panoramic radiography and two CBCT systems. Their results showed that, overall, sensitivity and specificity of CBCT were higher. Unfortunately their study did not include intraoral radiography, which would normally be used in assessment of impacted canines in this situation. Nonetheless, the studies on detection of root resorption in an endodontic context, in which intraoral radiography was the comparator imaging method (see Section 4.3.4), probably have relevance here.

Three clinical studies have considered resorption in relation to impacted teeth from a “Diagnostic Thinking Efficacy” and “Therapeutic Efficacy” perspective. The study of Haney et al (2010) on impacted maxillary canines reported that there was agreement between conventional and CBCT imaging on diagnosis of root resorption in the majority of assessments, while intra-rater reliability was lower for CBCT based assessments. Katheria et al (2010) found a significantly greater proportion of cases were scored by observers as showing resorption, although there was no consideration of the possibility of false positive scores. Alqerban et al (2011) compared observers‟ detection of root resorption in relation to impacted canine teeth in a clinical study with no reference standard. They reported a higher detection rate of “slight” resorption and a lower detection rate of “no resorption” using CBCT than when using panoramic radiographs, although they did not use intraoral radiographs for comparison.

The results of these studies should stimulate a note of caution. While it seems likely that the three-dimensional information of CBCT will identify resorption of roots more effectively than conventional intraoral radiographs, particularly on the facial and palatal surfaces, there is no research evidence to suggest that this information, or any

Table 4.1: Orthodontic applications of CBCT identified and reviewed 

Application of CBCT for orthodontics
Reference
Cleft palate assessment
Hamada et al 2005
Mussig et al 2005
Oberoi et al 2009
Oka et al 2006
Schneiderman et al 2009
Wortche et al 2006
Tooth position and localisation
Bedoya and Park 2009
Chaushu et al 2004
Gracco et al 2009
Kau et al 2005
Kau et al 2009
Nakajima et al 2005
Walker et al 2005
Liu et al 2007
Liu et al 2008
Mussig et al 2005
Swart et al 2008
Resorption related to impacted teeth
Kau et al 2005
Liu et al 2008
Measuring bone dimensions for mini-implant placement
Baumgaertel, 2009
Baumgaertel & Hans 2009a
Baumgaertel et al 2009b
Gracco et al 2006
Gracco et al 2007
Gracco et al 2008
Kim et al 2007
Park & Cho, 2009
For rapid maxillary expansion
Christie et al 2010
Garrett et al 2008
King et al 2007
3-dimensional cephalometry
Baumrind et al 2003
Surface imaging integration
Swennen & Scutyser 2006
Airway assessment
Maal et al 2008
Aboudara et al 2003
Kau et al 2005
Age assessment
Shi et al 2007
Yang et al 2006
Investigation of orthodontic-associated paraesthesia
Erickson et al 2003

changes in treatment, would alter the eventual outcomes. The Panel concluded that there was no strong evidence to support using CBCT as a “first line” imaging method for assessment of impacted maxillary canine or supernumerary teeth in the context of root resorption diagnosis, but that it may be indicated when conventional intraoral radiography did not supply adequate information.

CBCT may be indicated for the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth) where the current imaging method of choice is conventional dental radiography and when the information cannot be obtained adequately by lower dose conventional (traditional) radiography
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For the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth), the smallest volume size compatible with the situation should be selected because of reduced radiation dose. The use of CBCT units offering only large volumes (craniofacial CBCT) requires very careful justification and is generally discouraged
GP BP
 
Cleft palate
MSCT is a widely accepted method of assessing clefts, despite the significant radiation dose. The use of CBCT in this application has been the subject of several non-systematic reviews and descriptive studies (Müssig et al 2005; Hamada et al 2005; Wörtche et al 2006; Korbmacher et al 2007). Three-dimensional information can be used to determine the volume of bone needed for grafting and the adequacy of bone fill after surgery (Oberoi et al 2009; Shirota et al 2010). The Panel found this application of CBCT to be the simplest to support, in view of the established use of three-dimensional images and the potentially lower dose of CBCT.

Where the current imaging method of choice for the assessment of cleft palate is MSCT, CBCT may be preferred if radiation dose is lower. The smallest volume size compatible with the situation should be selected because of reduced radiation dose
GP

Temporary orthodontic anchorage using “mini-implants”
Several studies have used CBCT to measure the available bone thickness for placing temporary anchorage devices (TADs), also known as mini-implants (Gracco et al 2006; King et al 2006; Gracco et al 2007; Gracco et al 2008; Kim et al 2007; King et al 2007; Baumgaertel 2009; Fayed et al 2010). In our previous review it was noted that at the time “it was not clear when reviewing these studies whether the aim was to measure bone thickness (using CBCT as a convenient method of assessment) or whether CBCT was being proposed as a routine diagnostic tool”. Subsequently, it now appears that CBCT is being used by some as a clinical tool prior to placing TADs to identify optimal position and to avoid damage to roots (Lai et al 2010; Kapila et al 2011). The use of surgical guides based on CBCT data has also been suggested (Miyazawa et al 2010). Jung et al (2010) evaluated whether CT or CBCT was needed preoperatively for placement of TADs; they found that three dimensional imaging was only needed in rare cases of borderline dimensions.  

CBCT is not normally indicated for planning the placement of temporary anchorage devices in orthodontics
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4.2.2 Generalized application of CBCT for the developing dentition

Large volume (craniofacial) CBCT, imaging at least the entire facial skeleton, is currently being used as a routine tool for orthodontic-related radiological assessment by some clinicians (Kapila et al 2011; Smith et al 2011), particularly outside Europe. In view of the radiation doses involved and the (largely) paediatric age group of patients, this practice has become controversial and requires very critical consideration.

The European Guidelines on Radiation Protection in Dental Radiology (European Commission, 2004) highlighted the research performed, prior to the introduction of CBCT, which shows that clinical indicators and algorithms can reduce the numbers of radiographs without compromising patient treatment. Various studies have shown that radiographic information changes diagnosis and treatment plans in a minority of patients and there is specific evidence that cephalometric radiography is not always contributory to treatment planning (Han et al 1991; Bruks et al 1999; Nijkamp et al 2008; Devereux et al 2011). A flow-chart to support clinical decision making on the need for lateral cephalograms was included in the British Orthodontic Society Guidelines of 2002 and in a recent new edition (Isaacson et al 2008). Similar algorithms for selecting radiographs for orthodontic patients have been presented in European Guidelines (European Commission, 2004).

In our current review, no studies were identified relevant to “Diagnostic Accuracy”. This was not surprising, bearing in mind that orthodontic diagnosis does not normally involve detection of pathosis in the usual sense. Studies of measurement accuracy (see Section 4.1.1) are highly relevant to the tasks involved in orthodontic diagnosis and treatment planning and suggest that CBCT can produce accurate depictions of tooth size, tooth inter-relationships and related bony anatomy. There is evidence that cephalograms synthesised from CBCT volume datasets are accurate (Cattaneo et al 2008; Kumar et al 2007; Kumar et al 2008), although existing guidelines state that it is inappropriate to perform CBCT solely for the purposes of reconstructing two-dimensional panoramic and cephalometric images (Health Protection Agency, 2009), a view fully supported by the SEDENTEXCT Panel.

As in our previous review, the Panel felt that much of the literature on using large volume CBCT for routine orthodontic diagnosis and treatment was anecdotal, case report- and opinion-based, with a lack of evidence of significant clinical impact. While localised uses of CBCT (Section 4.2.1) have supporting research evidence, no scientifically valid evidence was identified to support the use of large volume CBCT at any stage of orthodontic treatment. Amongst the justifications of using CBCT instead of conventional radiography are that it allows accurate establishment of “boundary conditions” (Kapila et al 2011) in patients with bucco-lingually narrow alveolar bone, compromised periodontal or gingival anatomy and where movement of a tooth may involve translocation past another tooth or obstruction. The Panel recognised that there may be instances where three-dimensional information could assist in patient management, but could not find evidence to define these situations. The use of three-dimensional cephalometry has been presented by some authors as a means of improved diagnosis and management, but the evidence for this opinion is absent and there is no universally accepted method of three-dimensional cephalometric landmark analysis.

As such, the Panel could not recommend CBCT as a standard method of diagnosis and treatment planning in orthodontic practice. This is in accord with national guidelines within Europe (Isaacson et al, 2008; Haute Autorité de Santé 2009; Leitlinie der DGZMK, 2009) and the recommendation of the American Association of Orthodontists (American Association of Orthodontists, 2010). The Panel could, however, see the potential value of large volume CBCT for assessment of patients with complex craniofacial deformity requiring surgical or combined surgical/orthodontic intervention at 16 years or over as part of planning for the definitive procedure. Serial “monitoring” of skeletal growth should be discouraged.

Large volume CBCT should not be used routinely for orthodontic diagnosis
D
 
For complex cases of skeletal abnormality, particularly those requiring combined orthodontic/surgical management, large volume CBCT may be justified in planning the definitive procedure, particularly where MSCT is the current imaging method of choice
GP

When health professionals change their practice to adopt a more expensive diagnostic technique, particularly where there are radiation-related risks in a predominantly young patient age group, the onus is upon them to demonstrate significant improvement in patient outcomes.

Research is needed to define robust guidance on clinical selection for large volume CBCT in orthodontics, based upon quantification of benefit to patient outcome
GP


4.2.3 References



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4.3: Restoring the dentition 


4.3.1: Dental caries diagnosis


The use of CBCT as part of caries detection and diagnosis has been the subject of several laboratory research studies on extracted teeth. The relative ease of obtaining a valid reference standard means that the studies provide useful evidence of diagnostic value. In the previous review, we noted that much of the research had been performed using “limited” CBCT (small volumes with specific equipment) and that results are not transferable to all CBCT machines, as pointed out by Haiter-Neto et al (2008). Since then, several studies have been performed with alternative CBCT systems. Also since our previous review, a few studies have been performed which study occlusal caries.




Seven studies of proximal caries detection were included in the systematic review (Tsuchida et al 2007; Haiter-Neto et al 2008; Young et al 2009; Qu et al 2010; Kayipmaz et al 2010; Senel et al 2010; Zhang et al 2011). In five of these, in which Receiver-Operating Characteristic Curve (ROC) analysis was used, there was no significant difference in diagnostic performance between the CBCT systems and intraoral radiography. The other two studies (Haiter-Neto et al 2008; Young et al 2009), in which sensitivity and specificity were presented rather than ROC values, found higher sensitivity for detection of proximal dentine caries with a small volume, high resolution CBCT system, although Haiter-Neto et al (2008) reported no difference in overall true scores between CBCT and conventional radiographic imaging.



Three studies of occlusal caries detection were included in the systematic review (Haiter-Neto et al 2008; Young et al 2009; Kayipmaz et al 2010). All of these present data indicating increased sensitivity for occlusal caries diagnosis compared with conventional radiography. Young et al (2009) found that this was accompanied by a loss of specificity, while Haiter-Neto et al (2008) found (as with proximal caries detection) no differences in overall true scores. Any deterioration in specificity observed with CBCT imaging may reflect artefactual radiolucencies beneath the cusp enamel, reported by Young et al (2009). The studies of Kamboroglu et al (2010a and 2010b) could not be included in the systematic review, as they did not present recognised data on diagnostic accuracy; their work, however, suggests that occlusal caries depth measurements from CBCT correlate with histopathology better than intraoral radiographic images.



The current evidence suggests that limited CBCT has a similar diagnostic accuracy to conventional radiography for the detection of proximal caries in posterior teeth in vitro. For occlusal caries detection, the reports of higher sensitivity with CBCT suggest that further research would be of value. The representation of caries depth may be superior (Akdeniz et al 2006; Haiter-Neto et al 2008; Tsuchida et al 2007; Kamboroglu et al 2010a). One practical challenge to using CBCT for caries detection in the clinical situation, not addressed in the laboratory studies, is that metallic restorations will produce artefacts that would reduce diagnostic accuracy.



The Panel concluded that the evidence did not support the clinical use of CBCT for caries detection and diagnosis. Nonetheless, CBCT examinations performed for other purposes should be carefully examined for caries lesions shown fortuitously when performing a clinical evaluation (report).


CBCT is not indicated as a method of caries detection and diagnosis

B

4.3.2: Periodontal assessment 

The diagnosis of periodontal diseases depends on a clinical examination. This may be supplemented by radiological examination if this is likely to provide additional information that could potentially change patient management or prognosis. Radiographs do not have a role in diagnosis of periodontal disease, but are used as a means of demonstrating the hard tissue effects of periodontal disease, particularly the bony attachment loss. As pointed out in previous guidelines (European Commission, 2004), there is no clear evidence to support any robust recommendations on selection of radiological examinations. Those guidelines recommended that “existing radiographs, e.g. bitewing radiographs taken for caries diagnosis, should be used in the first instance”.



Conventional two-dimensional radiographs have significant limitations in demonstrating the periodontal attachment of teeth. Two-dimensional images do not show irregular bone defects or buccal/lingual attachments clearly. The attraction of a three-dimensional image is, therefore, considerable. The scientific literature on periodontal uses of CBCT is small and the Panel identified only two in vitro studies suitable for systematic review of diagnostic accuracy (Mol & Balasundaram 2008; Noujeim et al 2009). Using ROC analysis, Mol & Balasundaram (2008) demonstrated that one CBCT system was superior to conventional intraoral radiographs for diagnosis of the presence of periodontal bone loss in dried skeletal material. Noujeim et al (2009) created interradicular bone cavities in mandibles and found that a CBCT system was more accurate in detection of these than conventional radiography.


Several other studies were informally reviewed. Limited volume CBCT can provide accurate depiction of periodontal bone defects with good dimensional accuracy in laboratory studies (Mengel et al, 2005; Pinsky et al 2005; Mol & Balasundaram 2008), but with the latter study showing a less impressive performance for CBCT in the anterior regions. Interestingly, however, one study reported no significant differences in linear measurements between bone sounding, conventional radiography and CBCT (Misch et 2006), although buccal/lingual measurements could not be made by radiography. This lack of statistically significant difference between conventional and CBCT images was also reported in another laboratory study (Vandenberghe et al 2007). In a large ex vivo study, however, CBCT measurement accuracy was significantly better than intraoral radiography when cross-sectional images were used, but not when a panoramic reconstruction was employed (Vandenberghe et al 2008). The same study showed that CBCT was superior to intraoral radiography for crater and furcation defect imaging, reflecting case reports and non-systematic review opinion (Ito et al 2001; Kasaj & Willershausen 2007; Naitoh, 2006).

In a small clinical study of patients selected for periodontal surgery for maxillary molar furcation lesions, Walter et al (2010) found that pre-surgical CBCT estimates of furcation involvement of these teeth had a high level of agreement with intra-surgical findings. Takane et al (2010) used CBCT to facilitate guided tissue regeneration by allowing the prefabrication of the regeneration membrane material, while Bhatavadekar & Paquette (2008) reported the potential role of CBCT in evaluating the response to surgery and regenerative treatment of intrabony defects.

Overall, the literature related to use of CBCT in periodontal imaging is small, mainly laboratory-based and involves a limited number of CBCT systems. In terms of detection of periodontal bone loss, laboratory studies do not permit a comparison of CBCT with the primary diagnostic method i.e. probing of pockets. Furthermore, the impact of three-dimensional images upon management decisions and treatment impact in clinical practice has not been considered. Nonetheless, the general direction of the case series in the literature suggests that CBCT may have a role to play in the management of complex periodontal defects for which surgery is the treatment option. 


CBCT is not indicated as a routine method of imaging periodontal bone support

C

Limited volume, high resolution CBCT may be indicated in selected cases of infra-bony defects and furcation lesions, where clinical and conventional radiographic examinations do not provide the information needed for management

C

Where CBCT images include the teeth, care should be taken to check for periodontal bone levels when performing a clinical evaluation (report)

GP

4.3.3: Assessment of periapical disease


Diagnosis of periapical inflammatory pathosis is a common and important task for dentists. A number of case reports and non-systematic reviews have highlighted the value of CBCT for identification of periapical lesions in selected cases (Nakata et al 2006; Cotton et al, 2007; Patel et al, 2007). The research studies addressing this aspect of use of CBCT are limited by the extreme, probably insurmountable, difficulty of obtaining a true reference standard in human clinical studies. Our previous SEDENTEXCT review concluded that there was some evidence that CBCT identifies more periapical lesions on posterior teeth than traditional radiography, but further research studies assessing diagnostic accuracy were required. A subsequent study showed that CBCT identified more, and larger, periapical bone defects following apicectomy than did conventional radiography (Christiansen et al 2009). Őzen et al (2009) found improved observer agreement values when artificial periapical lesions were assessed with CBCT compared with conventional imaging. In the current review, four studies were identified that were eligible for systematic review (Stavropoulos & Wenzel, 2007; de Paula-Silva et al 2009; Patel et al 2009a; Soğur et al 2009), all of which were laboratory studies. Research designs were varied, using human and animal teeth and artificially created periapical lesions, but included one study performed in dogs in vivo with histopathologically validated periapical inflammatory lesions (de Paula-Silva et al 2009).



The current evidence suggests that high resolution CBCT may have higher sensitivity for detection of periapical lesions than conventional radiography in laboratory studies and that this is achieved without loss of specificity. However, the results should be interpreted with caution when based on the available studies. In practice, clinical signs and symptoms add significantly to the diagnostic process and radiological evidence is not always of critical importance. Furthermore, the relatively high economic cost of CBCT compared with intraoral radiography should not be ignored. Consequently, the Panel concluded that it was not appropriate to recommend CBCT as a standard method for diagnosis of periapical inflammatory disease.


CBCT is not indicated as a standard method for identification of periapical pathosis

GP

Limited volume, high resolution CBCT may be indicated for periapical assessment, in selected cases, when conventional radiographs give a negative finding when there are contradictory positive clinical signs and symptoms

GP

Where CBCT images include the teeth, care should be taken to check for periapical disease when performing a clinical evaluation (report)

GP
 

4.3.4: Endodontics

Conventional endodontic imaging relies on intraoral radiography. In multi-rooted teeth and more complex cases (e.g. suspected root perforations; resorptions and atypical canal systems) intraoral radiographs at different beam angulations are used to achieve a range of perspectives and allow parallax localisation. MSCT is impracticable for dentists and hard to justify on the basis of radiation dose. Endodontic treatment requires images in three phases of management: diagnosis, during treatment (working length estimation, master cone check image) and in post-treatment review. Endodontic treatment itself includes orthograde treatment and surgical endodontic procedures.



The three-dimensional images from CBCT appear to offer a valuable new method of imaging root canal systems, and there are several non-systematic reviews in the literature that give a favourable perspective (Cotton et al 2007; Nair et al 2007; Patel et al 2007). Endodontics requires, however, a high level of image detail, and it is important to remember that available dental CBCT systems offer resolutions far lower (by approximately one order of magnitude) than those of modern intraoral radiography. Furthermore, because endodontic treatment is a single tooth procedure, CBCT systems incapable of reducing the field of view to suitable dimensions will expose areas to radiation without patient benefit.

In our previous review, we highlighted a few studies in which a superior performance of CBCT in identifying root canals was reported but in which there was no independent reference standard (Loftag-Hansen et al 2007; Low et al 2008; Matherne et al 2008). We also found that the impact of CBCT on management decisions had not been addressed in any detail, although one study on posterior teeth (Loftag-Hansen et al 2007) reported that CBCT added additional clinically relevant information in 70% of cases. We concluded that research was needed to establish objectively the diagnostic accuracy of CBCT in identifying root canal anatomy and to quantify its impact on management decisions.

Since then, several descriptive clinical studies (Neelakantan et al 2010a; Wang et al 2010; Zheng et al 2010; Zhang et al 2011) and two laboratory studies (Baratto Filho et al 2009; Neelakantan et al 2010b) have used CBCT for imaging root canal anatomy in substantial patient populations or samples. All concluded that CBCT has a role to play in identification of root canal systems, notably for the identification of presence/ absence of a second mesio-buccal canal (MB2) in maxillary first molars.

In our current review, no study entirely satisfied our inclusion criteria for systematic review regarding the task of identifying root canals. One in vitro study (Blattner et al 2010), however, which investigated the identification of MB2 canals in maxillary first molars, provided the raw data to permit calculation of sensitivity and specificity and a decision was taken to include it in the formal review. In their small sample of teeth (n=20), sensitivity of observations using CBCT for identification of MB2 canals was 77% and specificity 83%. In a review paper, Scarfe et al (2009) reported unpublished data on the importance of the resolution of the CBCT system, suggesting that resolutions in the order of 0.12mm or less are optimal.

Because of the paucity of information about diagnostic accuracy of CBCT is assessment of root canal systems, the Panel could not support its general use for this purpose. Furthermore, the availability and use of an operating microscope may reveal root canal anatomy adequately without exposure to ionising radiation.



CBCT is not indicated as a standard method for demonstration of root canal anatomy

GP
 

Limited volume, high resolution CBCT may be indicated, for selected cases where conventional intraoral radiographs provide information on root canal anatomy which is equivocal or inadequate for planning treatment, most probably in multi-rooted teeth

GP
 
There was no literature regarding the use of CBCT during endodontic treatment or as part of post-treatment review eligible for systematic review. One laboratory study (Soğur et al, 2007) has shown that CBCT gave inferior images of the homogeneity and length of root canal fillings compared with intraoral radiographs.


On opinion-based grounds, the use of CBCT as part of planning and performing surgical endodontic procedures seems capable of justification. The literature relating to this area was very limited. Apart from case reports, one study (Rigolone et al, 2003), considered the use of CBCT for maxillary first molar teeth in the context of surgical access to the palatal root. While this was a descriptive study only, it considered the potential treatment planning value of understanding the three-dimensional relationships of anatomical structures, including the maxillary sinus. Further research is needed to consider the impact on management (surgical time, outcomes of treatment) before an evidence-based recommendation can be made. 

Limited volume, high resolution CBCT may be indicated for selected cases when planning surgical endodontic procedures. The decision should be based upon potential complicating factors, such as the proximity of important anatomical structures

GP
 
Our previous review highlighted several case reports and case series demonstrating a value of CBCT for imaging cases of inflammatory external root resorption (Maini et al, 2008 ; Cohenca et al, 2007; Walter et al, 2008; Patel et al, 2007; Patel & Dawood, 2007) and internal resorption (Cotton et al, 2007). Our recommendation at that time gave cautious approval of a potential diagnostic role for CBCT.



Subsequently, there have been several research studies of resorptions, including four which were suitable for inclusion in the systematic review (Liedke et al 2009; Patel et al 2009b; Kamboroğlu & Kursun 2010; Durack et al 2011). Three of these were laboratory studies using drilled holes in extracted teeth, while one was a clinical study (Patel et al 2009b). Three addressed external resorption (Liedke et al 2009; Patel et al 2009b; Durack et al 2011) and two considered internal resorption (Patel et al 2009b; Kamboroğlu & Kursun 2010). The clinical study was a useful attempt to obtain in vivo data, but suffers from a small sample size and, most importantly, a reference standard that is based upon the index tests (consensus based on CBCT and conventional radiographic images). The laboratory external resorption models suffer from a lack of comparability with the clinical situation, where adjacent bony changes will influence detection and where resorption cavities may be different to the drilled defects prepared for the research studies.


For external resorption, the two laboratory studies (Liedke et al 2009; Durack et al 2011) suggest that CBCT provides high sensitivity and specificity for detection of artificial lesions on mandibular incisors. For artificial internal resorption lesions, Kamboroğlu & Kursun (2010) found some limitations in sensitivity and specificity for the CBCT system tested but, unfortunately, they did not involve a comparator conventional imaging method. For both types of resorption, there is some evidence that resolution of the CBCT system influences diagnostic accuracy (Liedke et al 2009; Kamboroğlu & Kursun (2010).

External resorption is sometimes idiopathic and unexpected, but there are sub-groups of patients and teeth in which there is increased risk, notably after severe dental luxation and avulsion injuries. As pointed out by Durack et al (2011) resorption may progress rapidly and early treatment is advantageous. In such cases, the use of CBCT may be justified, but the timing of the imaging is unclear. The unpredictability of the condition means that a negative finding on one occasion would not exclude resorption at a later date. Repeated CBCT examinations would be hard to justify without research evidence of its value, particularly in children. On the basis of largely laboratory evidence on limited samples, the Panel found it difficult to arrive at a recommendation with a strong evidence grade.

Internal resorption is usually identified by chance on radiographs, so it seems likely that the role of CBCT would be reserved for cases where the resorption was extensive, where perforation of the root surface was in question and where three-dimensional information could help in decision-making on extraction or retention.



Limited volume, high resolution CBCT may be indicated in selected cases of suspected, or established, inflammatory root resorption or internal resorption, where three-dimensional information is likely to alter the management or prognosis of the tooth

D
 
As described in our previous review, there are several other potential applications of CBCT in endodontic practice (Table 4.2).  

Table 4.2: Endodontic uses of CBCT


Endodontic applications of CBCT
Reference
Differentiation of pathosis from normal anatomy
Relationships with important anatomical structures
Aiding management of dens invaginatus and aberrant pulpal anatomy
External resorption




Internal resorption
Lateral root perforation by a post
Accessory canal identification


Surgical management of fractured instrument
Aiding surgical endodontic planning
Cotton et al 2007
Cotton et al 2007
John 2008
Siraci et al 2006
Maini et al 2008
Cohenca et al 2007
Walter et al 2008
Patel et al 2007
Patel & Dawood 2007
Cotton et al 2007
Young 2007
Cotton et al 2007
Nair et al 2007
Patel & Dawood 2007
Tsurumachi et al 2007
Patel et al 2007
Patel & Dawood 2007
 
It seems likely from these case reports and non-systematic reviews that CBCT will have several valuable applications in selected cases. The absence of high quality studies available for this systematic review underlines the need for further research in this important area of dental practice.


4.3.5: Dental trauma

Trauma to teeth is a fairly common event faced by dentists in clinical practice. As described in our previous review, case reports and non-systematic reviews have included comments about the potential role of CBCT in assessment of dental injuries, as shown below:

Table 4.3: CBCT in dental trauma


Application of CBCT for dento-alveolar trauma
Reference
Root fractures




Luxation injuries

Avulsion
Root resorption as a post-trauma complication
Terakado et al 2000
Cohenca et al 2007a
Cotton et al 2007
Nair et al 2007
Patel & Dawood 2007
Cohenca et al 2007a
Patel et al 2007
Walter & Krastl 2008
Cohenca et al 2007b
Walter et al 2008
 
Unlike our previous review, on this occasion we were able to identify eight publications for the systematic review on the detection of root fractures using CBCT (Hassan et al 2009; Iikubo et al 2009; Wenzel et al 2009; Hassan et al 2010; Kamboroglu et al 2010; Melo et al 2010; Ozer 2010; Varshozaz et al 2010), seven of which were laboratory studies using extracted teeth and the other an in vivo animal study (Iikubo et al 2009). Some studies included root-filled teeth, while others did not. The study of Mora et al (2007) was not included in the review because it did not use a commercially available CBCT system, while that of Bernardes et al (2009) was excluded because it did not report diagnostic accuracy. All studies in which a comparison was made report significantly higher diagnostic accuracy for CBCT compared with conventional radiography, although “low” resolution scans (possibly around 0.3mm or larger voxel dimensions) may not offer this diagnostic advantage (Wenzel et al 2009; Hassan et al 2010; Kamboroglu et al 2010). The presence of root fillings in teeth may reduce specificity (increased false positive diagnoses) by artefact (Hassan et al 2010). Melo et al (2010) assessed diagnostic accuracy in the presence of root fillings without a comparison with conventional radiography and also reported problems with specificity. These workers also examined teeth containing metal posts; they found a lower sensitivity and specificity than for teeth with fractures but without posts. They also reported significantly inferior diagnostic performance when 0.3mm voxels were used, compared with 0.2mm voxels.



In practice, patients with suspected root fracture fall into two broad categories. First, there are those with acute trauma to anterior teeth, often children. Secondly, there are patients whose teeth may have fractured due to chronic trauma during normal function, usually in endodontically treated teeth. In the first group, the acute injuries may mean CBCT is not feasible due to treatment priorities and the problems associated with traumatised children of immobilisation for the scan. In such cases, it would seem reasonable to limit the radiological examination to simple radiographs and use CBCT at a later date if the conventional radiographs provide inadequate information for managing the patient. In the second group, the weight of evidence suggests that root fillings and posts limit diagnostic accuracy. Of course, in some of these cases diagnosis can be made, and prognosis assessed, on clinical examination evidence alone, so imaging may not always be indicated. In other cases conventional radiography may provide sufficient information for management.


The role of CBCT in more significant trauma is considered under “Surgical applications”, below.


4.3.6: References


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