DentalRadiography
Shanon Patel
Shalini Kanagasingam and Francesco Mannocci
Cone Beam Computed Tomography
(CBCT) in Endodontics
Abstract: Cone beam computed tomography (CBCT) is an extra-oral imaging system which produces 3-dimensional scans of the
maxillofacial skeleton. It is useful in overcoming the limitations of conventional radiography. CBCT is a valuable aid in providing additional
information for diagnosis and enabling more predictable management of complex endodontic problems compared to using intra-oral
radiographs alone.
Clinical Relevance: There are potential indications for the use of CBCT in diagnosis and treatment planning.
Dent Update 2010; 37: 373–379
One of the most important stages in
diagnosis and management of endodontic
problems is radiographic examination.
The periapical radiograph is widely used
in the field of endodontics to detect the
presence, location and size of periapical
lesions.1-3 It also reveals information about
root canal anatomy and proximity of
neighbouring anatomical structures.
In most endodontic cases,
the periapical radiograph is the image
of choice as it provides a high definition
S Patel, BDS, MSc, MClinDent, MFDS
MRD, Endodontic Postgraduate Unit,
King’s College London Dental Institute,
Guy’s Tower, Guy’s Hospital, St Thomas’
Street, London, SE1 9RT and 45 Wimpole
Street, London, S Kanagasingam, BDS
MFDS, Endodontic Postgraduate Unit,
King’s College London Dental Institute,
Guy’s Tower, Guy’s Hospital, St Thomas’
Street, London, SE1 9RT and Universiti
Kebangsaan Malaysia, Kuala Lumpur,
Malaysia and F Mannocci, MD DDS, PhD,
Endodontic Postgraduate Unit, King’s
College London Dental Institute, Guy’s
Tower, Guy’s Hospital, St Thomas’ Street,
London, SE1 9RT, UK.
July/August 2010
image at a low dose. However,
conventional radiographic techniques
have certain limitations. This paper
will review cone beam computed
tomography (CBCT) technology and
how this technology can be applied to
overcome some of the shortcomings
of conventional radiography in the
management of complex endodontic
problems.
Limitations of conventional
radiography
Conventional intra-oral
radiography has limitations which may
reduce the amount of useful information
gained.
Compression of 3-dimensional anatomy
The amount of information
gained from intra-oral radiographs
is limited by the fact that the
3-dimensional anatomy of the area
being radiographed is compressed
into a 2-dimensional image, which
limits their diagnostic value.3-5 Data are
obtained in the mesio-distal (proximal)
plane only, as the bucco-lingual view
(ie the third dimension) cannot be fully
assessed.
The spatial relationship of the
root(s) to their surrounding anatomical
structures and associated periapical
lesions cannot always be truly assessed
with conventional radiographs.6,7 In
addition, the location, nature and shape
of structures within the root under
investigation (eg root resorption) may be
difficult to gauge.3,8,9
Geometric distortion
Radiographs should be
taken with a beam aiming device as this
produces more geometrically accurate
images as compared to the bisecting
technique.10 However, it is not always
easy to position the radiographic film
parallel to the long axis of the tooth, for
example, patients with a shallow palatal
vault or gag reflex. The inability to do
this will affect the accuracy of the image
produced as some degree of geometric
distortion will be present.
Anatomical superimposition
Certain anatomical features
may mask or overlap the area of interest,
resulting in difficulty in interpreting
radiographic images.11 These anatomical
DentalUpdate 373
 DentalRadiography
Imaging technique
Panoramic radiograph
Cephalometric radiograph
Periapical radiograph
Occlusal radiograph
CBCT (6 cm field of view of standard mandible)
CBCT (6 cm field of view of standard maxilla)
Conventional CT scan of head
Table 1. Comparison of effective doses of various imaging techniques.22
Figure 1. The X-ray source and detector rotate once around the patient’s head. This results in a cylindrical
volume of data being captured. Sophisticated software reconstructs the data, which may then be
displayed in axial, sagittal and coronal planes.
features may be radio-opaque (eg the
zygomatic buttress) or radiolucent
(eg the maxillary sinus). The effect
of this anatomical superimpostion
is dependent on the degree of
bone demineralization, size of the
endodontic lesion and the nature
of the anatomical structures (ie its
thickness, shape and density of the
overyling anatomy). Some of these
problems may be resolved by the use
of CBCT.
What is CBCT?
Cone beam computed
tomography (CBCT) or digital
374 DentalUpdate
Effective doses (micro Sieverts)
13
1−3
1−8
8 in a cylindrical or spherical volume
75.3
36.5
2000
volume tomography (DVT) is an
extra-oral imaging system which
can produce 3-dimensional scans
of the maxillofacial skeleton.12 The
technology has existed since the
1980s in the medical field13 and has
more recently been developed for
use in dentistry. It has evolved into
a practical and relevant imaging
apparatus which is fast gaining
importance in dentistry.14
How does it work?
CBCT employs a pyramid
or cone-shaped X-ray beam. The
entire 3-dimensional volume of data
of the patient is acquired in a single
revolution of the x-ray source and
detector.2,15 The X-ray source and the
detector rotate between 180° to 360°
around the patient’s head, depending
on the CBCT scanner used. This results
of data, described as the field of view
(Figure 1).
Limited volume CBCT
scanners capture small volumes of
data that can include just two or three
individual teeth, for example, the
3D Accuitomo (J Morita Corporation,
Osaka, Japan) can capture a 40mm
height by 40mm diameter volume of
data which is similar in overall height
and width to a periapical radiograph.
The majority of CBCT
systems scan the patient in a seated
position. Scan times typically take
between 10–40 seconds, depending
on the scanner used and the exposure
parameters selected. The actual
exposure time is a fraction of this, only
about 2–5 seconds.
Sophisticated software
processes the collected data into a
format which closely resembles that
produced by medical CT scanners.
Reconstructed images are generated
within minutes (Figure 2).
The data acquired by
CBCT are captured in terms of
volume, which are made up of
voxels. With digital imaging, the
picture is composed of pixels. In the
case of CBCT, voxels are basically
3-dimensional versions of pixels. CBCT
voxels are isotropic, which means that
they are equal in all 3 dimensions.
Objects captured within the volume
can be accurately measured in various
directions.
Images can be displayed
in a number of different ways. For
example, images can be displayed
in the 3 orthogonal planes, axial,
sagittal and coronal, simultaneously.
Selecting and moving the cursor
on one image simultaneously alters
the other reconstructed slices. This
allows an area to be investigated
3-dimensionally in ‘real time’. Surface
rendering, which is a technique for
visualizing a geometric representation
of a surface from a 3-dimensional
July/August 2010

a b
c d
volume data set, makes it possible to
produce 3-dimensional images.
Why would you use CBCT?
CBCT may be useful in
complex endodontic cases where
conventional radiography has not
provided sufficient information. It can
provide additional information via
3-dimensional views in order to manage
a case predictably.
CBCT permits the clinician to
view areas of interest in any plane rather
than being restricted to the limited views
available with conventional radiography.
Most CBCT scanners are the size of a
panoramic machine and can therefore
be easily installed in dental practices. As
previously mentioned, scans are quick
(only 10–40 seconds) and can be done
with the patient sitting comfortably.
CBCT scanners use simpler,
and therefore less expensive, hardware
(X-ray source and detector) than
CT scanners and powerful low cost
computers,2,16 which means that the cost
of CBCT scanners is not prohibitively
July/August 2010
e
expensive. This has resulted in an
increase in its uptake in dental
practices,14,17 although these scanners
are more costly than conventional
radiographic equipment.
CBCT scans offer a significant
radiation dose reduction as compared
to medical CT. Previous studies suggest
that it can be almost as low as a dental
panoramic radiograph.18–21 Limited
volume CBCT scanners are best suited
for endodontic imaging of only one
tooth or two neighbouring teeth, as
there is a smaller field of view, which
is similar in size to a conventional
periapical radiograph. A more recent
study agreed that the doses from
CBCT were much lower compared
to medical CT. However, the authors
stated that the effective dose was
significantly higher than conventional
radiographic techniques.22 Table 1
compares the effective radiological
dose from conventional imaging
techniques to CBCT, as quoted from
the abovementioned article.22 With this
in mind, the use of CBCT should be
justified over conventional radiography,
DentalRadiography
Figure 2. (a–d) CBCT produces high resolution
multiplanar images (b): green plane (sagittal
slice-d); blue plane (coronal slice-c); red plane
(axial slice-a). (a) Axial CBCT slice clearly shows 2
canals in an upper central incisor in a case of dens
in dente (red arrows) as compared to a periapical
radiograph (e).
especially when treating paediatric
patients. Several studies appear to show
the 3-dimensional geometric accuracy
of CBCT.23–26
When would you use it?
CBCT should be used in cases
where conventional radiography has
not provided sufficient information. The
following are some indications for the
use of CBCT.
Detection of apical periodontitis
A CBCT scan may be helpful
in investigating the presence or
absence of periapical lesions in cases
whereby information from conventional
radiographs has been inconclusive.
CBCT enables radiolucent endodontic
lesions to be detected before
radiolucent lesions are diagnosed on
conventional radiographs (Figure 3).
Lofthag-Hansen et al 27 demonstrated
that CBCT scans resulted in 62% more
periapical lesions being detected as
compared to two angled periapical
DentalUpdate 375
 DentalRadiography
a This could help exclude cases of non-
b and maxillary sinus, to be clearly
Figure 3. (a) Periapical radiograph shows lower
left first molar with no obvious periapical lesion.
(b) Sagittal CBCT slice shows periapical lesions
associated with mesial and distal roots (red arrows)
of the same lower left first molar.
radiographs. Patel et al28 found CBCT
to be more sensitive than conventional
radiographic films in detecting simulated
periapical lesions in dried human jaws.
Ozen et al29 assessed the diagnostic
potential of two different CBCT units
and compared this with intra-oral digital
and conventional film in the detection of
periapical lesions. They concluded that
the two CBCT units performed similarly
and both performed better than intra-oral
digital and film radiography in detecting
periapical lesions.
Earlier detection of periradicular
radiolucent changes with CBCT should
result in earlier identification and
management of endodontic disease.
This could lead to a better outcome from
endodontic treatment as teeth could
be treated sooner.30 CBCT may reveal
the presence of previously undiagnosed
periapical disease, especially in cases
where patients have poorly localized
symptoms and periapical radiographs
seem to show no evidence of disease.2,3,31
376 DentalUpdate
with dental trauma as compared to
odontogenic orofacial pain (eg atypical multiple intra-oral radiographs taken
facial pain). using a paralleling device. CBCT scans are
also useful for detecting cortical bone
fractures.5
Pre-surgical assessment
Three dimensional imaging
allows the anatomical relationship of the
root apices to important neighbouring
a
anatomical structures, such as the
inferior dental canal, mental foramen
identified in any plane.3 Rigolone et
al32 concluded that CBCT may play an
important role in periapical microsurgery
of palatal roots of maxillary first molars.
The presence or absence of the maxillary
sinus between the roots can be assessed
by measuring the distance between the
cortical plate and the palatal root apex.
b
By selecting relevant views,
the thickness of the cortical plate, the
cancellous bone pattern, fenestrations,
as well as the inclination of the roots
of teeth planned for periapical surgery,
can be accurately determined pre-
operatively.31 Root morphology, bony
topography and the number of root
canals can be assessed. Unidentified
(and untreated) root canals in root-
treated teeth may be identified using
axial slices which may not be readily
identifiable with periapical radiographs.33
The size, location and extent of the
periapical lesion can also be gauged,
while the actual root to which the lesion
is associated can be identified. This
additional information will prove useful c
in surgical planning.
Assessment of dental trauma
Case reports and expert
opinion suggest that CBCT is likely to be
useful in diagnosis and management of
dento-alveolar trauma.2,3,5 The nature and
severity of alveolar and luxation injuries
can be assessed from just one scan,
from which multiplanar views can be
selected and assessed with no geometric
distortion or anatomical noise. A recent
study has shown that CBCT can be
used to detect horizontal root fractures
and that it performed better than the Figure 4. (a) Periapical radiograph of lower right
2-dimensional intra-oral, conventional as first molar with deep carious lesion, showing
well as digital radiographic methods.34 mesial and distal roots. (b) Coronal and (c)
axial CBCT slices confirmed the presence of an
As an extra-oral technique, CBCT is
additional distobuccal root (red arrows).
much more comfortable for patients
July/August 2010

a c
d What are the limitations of
b order of 15–20 line pairs/mm.38 CBCT
Assessment of root canal anatomy
Conventional radiographs
do not always reveal the actual number
of canals present in a tooth (Figure 4).
Matherne et al35 conducted an in vitro
study which evaluated digital radiography
systems with CBCT for comparing the
number of root canals in 72 extracted
teeth. They found that, with digital intra-
oral radiography, endodontists failed to
identify at least one root canal in 40% of
teeth, despite taking parallax radiographs.
Though it must be noted that the teeth
were not subsequently sectioned to
confirm the true number of root canals
compared with the ‘gold standard’ CBCT
data.
July/August 2010
Figure 5. (a) Periapical radiograph of lower left
central incisor showing an internal resorptive
lesion. (b-d) Series of CBCT slices which show the
extent of the internal resorptive lesion, perforating
the lingual surface of the tooth (red arrow).
CBCT reconstructed images
are indispensable in the diagnosis and
management of resorption lesions.36 It
is able to disclose the extent and exact
location of the lesion, determine the
‘portal of entry’ of the resorptive lesion
and also reveal previously undetected
resorptive lesions.8,37 With this additional
information, decision-making on
treatment strategies may be more
predictable, eg CBCT slices may reveal
if an external cervical resorptive lesion
has perforated the root canal, or if an
internal resorptive lesion has perforated
into the adjacent periodontium (Figure
5).
The authors of this review
DentalRadiography
paper have found CBCT reconstructed
scans invaluable for assessing teeth
with unusual anatomy, such as teeth
with an unusual number of roots,
dilacerated teeth and dens in dente
(Figure 2). In these situations, the exact
location and anatomy of the root canal
can be assessed, allowing successful
management of the case. Previously,
even with the aid of magnification, the
anatomy of such a tooth may not be truly
appreciated.
CBCT?
Currently, the images
produced with CBCT technology do
not have the resolution (ie detail) of
conventional radiographs. The spatial
resolution of conventional direct-action
packet film and digital sensors is in the
images only have a spatial resolution
of 2 line pairs/mm.39 However, CBCT
technology is improving, and resolution is
improving.
A significant problem
which can affect the image quality and
diagnostic efficacy of CBCT images is the
scatter and beam hardening caused by
high density neighbouring structures,
such as metal posts and crowns.40 If this
scattering and beam hardening is within
or close to the tooth being assessed,
the resulting CBCT images will be of
minimal diagnostic use27,41 (Figure 6). The
potential presence of artefacts also poses
a problem in this respect.
As shown in Table 1, the
significantly higher radiation dose of
CBCT as compared to conventional
radiographic techniques should be kept
in mind so as to limit its usage to very
specific situations.
Discussion
CBCT technology is constantly
being developed and advanced. Scanners
are becoming more affordable, thus
making CBCT technology a viable option
in dental practices. However, it must
be stressed that users of CBCT must be
adequately trained in CBCT radiology, as
well as interpretation of these images,
as they are completely different from
DentalUpdate 377
 DentalRadiography
a is proving to be an indispensable
b 15: 186–189.
Figure 6. (a, b) Lower CBCT slices of lower central
incisors which had undergone apicectomies and
had retrograde amalgam fillings placed, which
have caused beam scattering and hardening.
conventional radiography systems.
CBCT captures a considerable amount of
data. All the data on the scan (not just
the area of interest) must be reviewed
and any anomalies must be reported
and acted upon by the dental surgeon
requesting the scan, or by a specialist
radiologist.17,42
Three-dimensional CBCT
scans may complement conventional
two-dimensional radiographic
techniques which, at present, have
higher resolution than CBCT images,
therefore making the most of both
systems.43 This should result in more
accurate diagnosis and therefore
improved decision-making for the
management of complex endodontic
problems. Ideally, its use should
be incorporated into endodontic
postgraduate programmes, as it
378 DentalUpdate
supplementary diagnostic tool.
It must always be kept in mind
that patient radiation exposure should be
as low as reasonably practicable (ALARP).
After all, CBCT uses ionizing radiation
and is therefore not without risk. As
previously mentioned, the effective
dose of CBCT is considerably higher
than conventional imaging techniques.
Evidence-based selection criteria for
CBCT use would be essential for guiding
clinicians.
Conclusion
Finally, the benefits of a
CBCT investigation must outweigh
any potential risks.43,44 Consequently,
endodontic cases should be judged
individually, until further evidence is
available. CBCT should not be used
routinely. It should only be considered for
the management of complex endodontic
cases, after conventional radiographic
views have been taken and found to be
inadequate.
Acknowledgements
We thank Cavendish
Imaging, London, UK and the Radiology
Department, Guy’s and St Thomas’
NHS Trust for their help and advice in
preparation of this article.
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