4.4 Surgical applications
Surgery
of the dental and maxillofacial region encompasses minor procedures (oral
surgery) that may be performed in dental practices and major surgery
(maxillofacial surgery) that would always be carried out by specialists, often in
a hospital environment.
4.4.1
Exodontia
There
is no literature related to the use of CBCT as part of the pre-extraction
assessment of erupted teeth and there seems no good reason to suggest its use
for this purpose. The literature concentrates on unerupted teeth, principally
lower third molars, as demonstrated in the systematic review performed by
Guerrero et al (2011).
A
number of clinical studies, case series and non-systematic reviews have been
published on the use of CBCT for pre-surgical assessment of impacted third
molars including Heurich et al (2002), Nakagawa et al (2002), Danforth et al
(2003), Nakagawa et al (2007), Friedland et al (2008), Neugebauer et al (2008),
Nakayama et al (2009), Tantanapornkul et al (2009), Lübbers et al (2010), Suomalainen
et al (2010) and Yamada et al (2011). The broad conclusion of reviewing these
studies is that CBCT may offer advantages for the surgeon in showing the
anatomical position and relationships of mandibular third molars where there is
a close inter-relationship between the third molar root and the mandibular
canal (inferior dental canal), but that CBCT should not be used routinely for
all third molar pre-surgical assessments.
Two
studies satisfied the inclusion criteria for the review of diagnostic accuracy
(Tantanapornkul et al 2007; Ghaeminia et al 2009), both of which considered the
relationship between the mandibular third molar root and the mandibular canal
and a reference standard of intra-surgical direct visualisation. Cone-beam CT
was significantly superior to panoramic images in predicting neurovascular
bundle exposure during extraction of impacted mandibular third molar teeth,
with impressive sensitivity (Tantanapornkul et al 2007). The more recent study
by Ghaeminia et al (2009), however, provided apparently contradictory findings.
They found no significant difference in sensitivity and specificity between
panoramic radiography and CBCT in predicting exposure of the mandibular canal.
The difference in results of the two studies probably reflects different case
selection. Direct exposure of the canal during surgery is, however, not a
prerequisite for post-operative nerve damage. Injury may occur by pressure
effects through thin intervening bone. As pointed out by Ghaeminia et al
(2009), CBCT offers the advantage of identifying bucco-lingual position of the
canal. Other factors, such as complex root morphology, may also favour the use
of a cross-sectional imaging technique.
Where conventional radiographs suggest a direct
inter-relationship between a mandibular third molar and the mandibular canal,
and when a decision to perform surgical removal has been made, CBCT may be
indicated
C
|
It
is important to ensure that the above recommendation does not lead to a “drift”
towards routine use. The incidence of post-surgical dysaesthesia after third
molar removal is very low in the hands of experienced surgeons and there is no
evidence of improved outcomes through the use of CBCT. By “direct
inter-relationship”, the Panel intended to highlight the features on
conventional radiographs which are related to postoperative dysaesthesia:
“darkening” of the root, interruption of the canal wall and diversion of the
canal (Rood & Shehab 1990). Each case must be judged on an individualised
assessment of risk.
CBCT may be indicated for pre-surgical assessment
of an unerupted tooth in selected cases where conventional radiographs fail
to provide the information required
GP
|
4.4.2
Implant dentistry
In
investigating an implant site, a surgeon requires information on bone volume
and quality, topography and the relationship to important anatomical
structures, such as nerves, vessels, roots, nasal floor, and sinus cavities
(Harris et al 2002).
In
2002, a Working Group of the European Association of Osseointegration (EAO)
devised consensus guidelines on imaging for implant dentistry (Harris et al
2002). They did not include any comment on CBCT. They did, however, describe
criteria for use of “cross-sectional imaging” (at that time, spiral tomography
and MSCT).
The
EAO guidelines made the following key points:
·
Clinicians
should decide if a patient requires cross-sectional imaging on the basis of the
clinical examination, the treatment requirements and on information obtained
from conventional radiographs.
·
The
technique chosen should provide the required diagnostic information with the
least radiation exposure to the patient.
·
“Standard”
imaging modalities are combinations of conventional radiographs.
·
Cross-sectional
imaging is applied to those cases where more information is required after
appropriate clinical examination and standard radiographic techniques have been
performed.
The EAO
guidelines presented valuable information on the special clinical situations in
implant dentistry when cross-sectional imaging is required (Table 4.4). The
guidelines go on to explain that cross-sectional imaging is of principal value
in pre-operative assessment and treatment planning, but that it is not part of
a “routine protocol” for post-operative examinations “unless there is a need
for assessments in situations where some kind of complications have occurred,
such as nerve damage, postoperative infections in relation to nasal and/or
sinus cavities close to implants” (Harris et al 2002).
While these
criteria for cross-sectional imaging are subjective in nature, relying heavily
on subjective “clinical doubt”, they do offer useful guidance. The Panel had
neither the remit nor the expertise to reconsider the EAO guidelines. The
primary question for clinicians is whether or not cross-sectional imaging is
required for implant planning, rather than whether CBCT is required.
Nonetheless, CBCT has different radiation dose implications and different
capabilities. Consequently, in 2009 the Panel recommended that the EAO reviewed
its 2002 consensus guidelines on the use of imaging in implant dentistry to
take into account the availability of CBCT. The EAO are currently undertaking
this review.
There
is a substantial literature related to the use of CBCT in dental implantology.
Implant treatment planning has been the most frequent use of MSCT in dentistry.
Nonetheless, there were no studies identified for inclusion in the systematic
review on diagnostic accuracy, which was not altogether surprising. Studies on
geometric accuracy for linear measurements, however, are of obvious importance
in implant planning; these show high accuracy (see Section 4.1.1). Overall, the
evidence suggests that CBCT has sufficient geometric accuracy for linear
measurements in implant dentistry. Interestingly, however, one study compared
ridge mapping with CBCT, using a direct surgical measurement as a reference
standard, and found that CBCT was less consistent than ridge mapping and that
it did not add any additional information (Chen et al 2008). Furthermore, as
pointed out in Section 4.1.1, accuracies reported in laboratory studies may be
not as good in patients due to minor movement during scanning. As such, the
Panel agreed that clinicians should use their clinical judgement and a margin
of safety when planning implants close to important anatomical structures.
Apart from geometric accuracy, an important aspect is the ease of visualisation
of important structures on CBCT. Loubele et al 2007 demonstrated better
subjective image quality for important structures for CBCT compared with MSCT.
Mengel et al (2006) showed promising results for visualisation of peri-implant
defects in an animal study. CBCT resolution may, however, be important in the
efficacy of visualising fine detail of cortical bone thickness (Razavi et al
2010).
Table 4.4: Special indications for cross-sectional imaging
(adapted from Fig. 2b in Harris et al 2002).
Maxilla
|
Single
tooth
|
a.
incisive canal
b.
descent of maxillary sinus
c.
clinical doubt about shape of alveolar ridge
|
Partially
dentate
|
a.
descent of maxillary sinus
b.
clinical doubt about shape of alveolar ridge
|
|
Edentulous
|
a.
descent of maxillary sinus
b.
clinical doubt about shape of alveolar ridge
|
|
Mandible
|
Single
tooth
|
a.
clinical doubt about position of mandibular canal
b.
clinical doubt about shape of alveolar ridge
|
Partially
dentate
|
a.
clinical doubt about position of mandibular canal or mental foramen
b.
clinical doubt about shape of alveolar ridge
|
|
Edentulous
|
a.
severe resorption
b.
clinical doubt about shape of alveolar ridge
c.
clinical doubt about position of mandibular canal if posterior implants are
to be placed
|
Much
research interest has focused on the ability of CBCT to image neurovascular
structures in the jaws, with several descriptive studies and case series being
reported (Angelopoulos et al 2008; Pires et al 2009; Uchida et al 2009; Makris
et al 2010; Naitoh et al 2010). This work is set in the context of the risk of
haemorrhage during surgery, particularly in the floor of the mouth where the
consequences can be severe, and on post-surgical neuropathy. The Panel
recognise that this risk is of significance to patient outcome and well-being.
Naitoh et al (2010) concluded that there was no significant difference between CBCT
and MSCT for the depiction of fine anatomical features in the mandible
associated with neurovascular structures, although their results may not be
applicable to the wide range of CBCT and MSCT systems, exposure protocols and
other variables influencing image quality.
The
EAO guidelines emphasise the importance of relating accurately the image data
to the surgical situation: “The diagnostic information can be enhanced by
the use of appropriate radiopaque markers or restorative templates. However,
this information cannot be transferred exactly to the surgical site as long as
no intraoperative navigation is used” (Harris et al 2002). Several papers
have been published relating to the accuracy of implant placement using
surgical guides manufactured using CBCT datasets (Fortin et al 2002; Fortin et
al 2003; Sarment et al 2003; van Steenberghe et al 2003; Nickenig & Eitner
2007; van Assche et al 2007; Nickenig & Eitner 2010; Arisan et al 2010; van
Assche et al 2010; Al- Ekrish & Ekram, 2011). These studies suggest that,
within specified limits of error, CBCT is an effective means of providing data
for the manufacture of surgical guides in implant dentistry.
There
are a large number of publications (case studies; non-systematic reviews;
descriptive studies) that illustrate the use of CBCT in implant dentistry. Many
of these were consulted during the review by members of the Panel to help build
the body of knowledge in developing the guidelines (Almog et al 2006; Arisan et
al 2010; Blake et al 2008; Bousquet & Joyard 2008; Fan et al 2008; Ganz
2005; Ganz 2006; Ganz 2008; Ganz 2010; Garg 2007; Guerrero et al 2006; Hatcher
et al 2003; Moore 2005; Peck & Conte 2008; Sato et al 2004). These
publications make it clear that CBCT is being used widely for implant dentistry.
As such, The Panel makes the following recommendations:
CBCT is indicated for cross-sectional imaging
prior to implant placement as an alternative to existing cross-sectional
techniques where the radiation dose of CBCT is shown to be lower
D
|
For cross-sectional imaging prior to implant
placement, the advantage of CBCT with adjustable fields of view, compared
with MSCT, becomes greater where the region of interest is a localised part
of the jaws, as a similar sized field of view can be used
GP
|
While the emphasis has been on assessment of
bone quantity, there is interest in “bone quality” assessment using CBCT. Bone
density evaluation of implant sites is feasible using MSCT (de Oliveira et al
2008). Since Barone et al (2003), a number of studies have, however, tried to
derive Hounsfield Units (HUs) from CBCT. Some studies suggest this is
potentially feasible, with moderate or good correlations between CBCT-derived
HUs and density data from other sources (Aranyarachkul et al 2005; Lagravère et
al 2006; Lagravère et al 2008; Mah et al 2010; Nomura et al 2010). Song et al
(2009) reported strong correlations between CT numbers and implant primary
stability. Lee et al (2007), however, found only moderate correlations between
drilling resistance torque and HU values. Bryant et al (2008) showed
substantial changes in HU values of a region were produced in an iCAT scanner
depending on the axial position in the slice due to the effect of the mass of
material within and outside the scan volume. Recently, Nackaerts et al (2011)
compared MSCT and CBCT scanners and reported that intensity values in CBCT
images were not reliable, because the values are influenced by the scanner
device, the imaging parameters and the positioning of the field of view. It is
clear from this work that there is uncertainty regarding the use of CBCT to
derive HU or other “density” measures of bone and that it cannot be recommended
for this purpose in everyday practice.
4.4.3
Bony pathosis
Occasionally,
a dentist may be presented with a patient with an unusual bony lesion. Cysts,
tumours and a wide range of esoteric lesions can present in the jaws causing
symptoms and/or clinical signs; some may only be detected by chance on
conventional radiography. There are numerous case reports of bony lesions that
have been imaged using CBCT (Abdelkarim et al 2008; Araki et al 2006; Araki et
al 2007; Barragan-Adjemian et al 2009; Closmann & Schmidt 2007; Fullmer et
al 2007; Guttenberg 2008; Harokopakis-Hajishengallis &Tiwana 2007; Kamel et
al. 2009; Kumar et al 2007; Nakagawa et al 2002; Quereshy et al 2008; Rodrigues
& Estrela 2008; Rozylo-Kalinowska & Rozylo 2001; Scherer et al 2008;
Schulze et al 2006; Schulze 2009; Smith et al 2007; Ziegler et al 2002). While
these are too wide ranging in pathoses and are case reports/series rather than
formal studies, it seems reasonable to predict that CBCT will have a useful
role in the assessment of bony pathosis of the jaws.
Four
studies falling into this clinical category were reviewed formally by the Panel
in the context of diagnostic accuracy (Hendrikx et al 2010; Momin et al 2009;
Rosenberg et al 2010; Simon et al 2006). Momin et al (2009) measured the
diagnostic accuracy of high resolution cone-beam CT compared with panoramic
radiography in the assessment of mandibular invasion by gingival carcinoma,
validated by histopathological findings after surgery. They found high
sensitivity of diagnosis based on CBCT, although specificity was only similar
to panoramic radiography. They also noted the challenge of restoration-related
artefacts and false positives from periodontal disease. Hendrikx et al (2010)
reported higher sensitivity and specificity for CBCT in detecting mandibular
invasion by carcinoma, validated by histopathology, compared with both
panoramic radiography and MR, although their results were not statistically
significant due to sample size. The results of these studies are promising and
further research is needed to investigate the role of CBCT in management of
patients with oral carcinoma.
The
Panel considered that in cases of oral carcinoma, other cross-sectional imaging
(MSCT, MR) would be performed first as part of diagnostic work-up, as was the
case in the study of Hendrikx et al (2010). The Panel concluded that, on the
basis of current research, the role for CBCT was likely to be in cases where
these imaging techniques could not confirm or refute bony involvement and where
the diagnosis of bone involvement would change a treatment plan. As such, the
Panel maintain the guideline established as a Basic Principle (Section 3).
|
Where it is likely that evaluation of soft
tissues will be required as part of the patient‟s radiological assessment,
the appropriate initial imaging should be MSCT or MR, rather than CBCT
BP
|
Limited volume, high resolution, CBCT may be
indicated for evaluation of bony invasion of the jaws by oral carcinoma when
the initial imaging modality used for diagnosis and staging (MR or MSCT) does
not provide satisfactory information
D
|
The
studies of Simon et al (2006) and Rosenberg et al (2010) both considered
whether CBCT could be used to differentiate cysts from apical granulomas.
Although Simon et al (2006) suggested that “CBCT may provide a more accurate
diagnosis than biopsy and histology”, analysis of their results by the Panel
indicated that CBCT had high sensitivity for diagnosis of cysts but limited
specificity (i.e. over-diagnosis of cysts). The work of Rosenberg et al (2010)
found poor accuracy for CBCT in differentiating cysts from granulomas and they
concluded that CBCT was not a reliable diagnostic method.
In
the context of bony pathosis generally, the Panel felt that it was important
that unless dentists are treating patients themselves (as opposed to referral
to an oral surgeon) it is probably correct to leave the choice of imaging to
the surgeon who intends to treat the patient.
4.4.4
Facial trauma
The
management of significant maxillofacial trauma is outside the normal working
practice of a dentist and limited to specialist/ hospital practice. Fractures are
conventionally imaged using plain radiography or MSCT, depending on custom and
practice. Generally speaking, as stated by Schoen et al (2008), “when
radiographs do not show clearly the degree of displacement, type of fracture or
degree of comminution, for example, in suspected fractures of the condylar
head, CT or cone-beam CT is indicated”. The potential role of CBCT in
assessment of maxillofacial fractures has been reviewed by Shintaku et al
(2009).
For maxillofacial fracture assessment, where
cross-sectional imaging is judged to be necessary, CBCT may be indicated as
an alternative imaging modality to MSCT where radiation dose is shown to be
lower and soft tissue detail is not required
D
|
In foreign body detection and localization, CBCT
is suitable for imaging high attenuation materials but not as effective as MSCT
for lower attenuation objects (Eggers et al 2007; Stuehmer et al 2008).
4.4.5
Orthognathic surgery
This
application is closely allied to orthodontics and the evidence presented in
Section 4.1.1 regarding measurement accuracy is also relevant here. Whereas in
Section 4.2.2 the Panel did not support the routine use of CBCT for orthodontic
assessment, the patients likely to be candidates for orthognathic surgery (with
significant facial deformity) are more likely to benefit from cross-sectional
imaging.
CBCT is indicated where bone information is
required, in orthognathic surgery planning, for obtaining three-dimensional
datasets of the craniofacial skeleton
C
|
4.4.6
Temporomandibular joint
The
overwhelming majority of patients with symptoms and signs related to the
temporomandibular joint (TMJ) are suffering from myofascial pain/dysfunction or
internal disc derangements. Bony abnormality is not seen in the former and only
occasionally in the latter. In such cases, radiographs do not add information
of relevance to management. Where imaging of the TMJ disc is needed, Magnetic
Resonance Imaging (MR) is the method of choice.
Other
pathoses encountered in the TMJ include osteoarthrosis and rheumatoid
arthritis. In both these conditions, there are often bony changes that may be
detectable on conventional radiographs and CBCT. When considering the
justification for CBCT, however, the clinician should consider whether the
information obtained will alter the management of the patient. The
identification of bony erosions, remodelling or deformity may be purely
documentary and have no impact on treatment strategy.
The
available evidence included four diagnostic accuracy studies with valid
reference standards (Honda et al 2006; Hintze et al 2007; Honey et al 2007;
Marques et al 2010) and a selection of case series/ non-systematic reviews
(Zhao et al 2003; Honda et al 2004; Tsiklakis et al 2004; Honda & Bjornland
2006; Sakabe et al 2006; Kijima et al 2007; Krisjane et al 2007; Meng et al
2007; Lewis et al 2008; Huntjens et al 2008; Alexiou et al 2009; Ikeda &
Kawamura 2009; Barghan et al 2010; Alkhader et al 2010a; Farronato et al 2010).
There was also one systematic review of imaging of TMJ erosions and osteophytes
which considered CBCT evidence (Hussain et al 2008) and one recent review of
imaging of the TMJ (Petersson 2010).
CBCT
images provided similar diagnostic accuracy to MSCT for condylar osseous
abnormality (Honda et al 2006) and greater accuracy than panoramic radiography
and linear tomography in the detection of condylar cortical erosion (Honey et
al 2007). Hintze et al (2007), however, found no differences in diagnostic
accuracy for condylar abnormality between CBCT and conventional tomograms. The
literature also reveals one comparative study in which CBCT acted as the index
test for osseous abnormalities compared with MR (Alkhader et al. 2010b). The
latter reported low sensitivity of MR in the detection of osseous change.
While
there is good evidence for the accuracy of CBCT for detection of osseous
abnormalities of the TMJ, the Panel was not prepared to suggest routine use of
CBCT for examination of the TMJ in the absence of evidence about its impact
upon treatment decisions. As stated by Petersson (2010), according to the
current version of the Research Diagnostic Criteria for Temporomandibular
Disorders (RDC ⁄TMD), imaging of the TMJ is not required for a diagnosis.
Furthermore, there is no clear evidence for when TMD patients should be examined
with imaging methods. The Panel concluded that CBCT could be considered as an
alternative to MSCT, if radiation dose with CBCT is shown to be lower.
Where the existing imaging modality for
examination of the TMJ is MSCT, CBCT is indicated as an alternative where
radiation dose is shown to be lower
B
|
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