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Continuing Education

2 CE credits
This course was written for endodontists and general dentists

Cone beam in endodontics

Bertrand Khayat and Jean-Charles Michonneau evaluate cone beam imaging technology in endodontics
Conventional or surgical endodontic treatment has become a reliable procedure. New technology (operating microscope, rotary instruments, ultrasonics) allows us to treat increasingly complex cases. However, conventional radiography, which has become digital in the past 10 years, can only show an image in two dimensions of an object in three dimensions. This kind of image usually shows basic information to the practitioner, but remains insufficient for a more detailed analysis. The use of conventional threedimensional imaging scanners has opened new horizons in the area of diagnosis and theapeutics. For many years reserved for implantology, there is now an emergence within dental clinics of a new generation of threedimensional imaging device: the cone beam. rays. Unfortunately, the cost of these generators remains high.

Resolution
Endodontics requires an image as precise as possible. Root canal anatomy, calcifications and the presence of hairline fractures should ideally be viewed on a three-dimensional image. The image acquired by the cone beam is composed of voxels that determine the image resolution. The voxels are isotropic, i.e. they have edges of identical dimensions. Thus, slices rebuilt from these voxels will have the same spatial resolution whatever their orientation. The size of the voxels varies depending on the type of device (Table 1). The size of the voxels is on average 0.15mm which is slightly lower than the size of a pixel on a conventional scanner. However, the final usuable resolution will be obtained only after computerising the image. There are great inconsistencies in the quality of this process which is crucial for the final image. Some models with a small size voxels offer blurred/hazed three-dimensional images and therefore are more difficult to use in endodontics. Haze is a defect that degrades the image quality. It is generally caused by a lack of homogeneous response of the digital sensor. The surface receptors of some sensors are more sensitive than others to ionizing radiation and create a stronger signal from the same exposure. Haze causes loss of sharpness in the detail and creates grain on the picture. This haze is structural and permanent; it remains the same for each exposure. It may be reduced using computer processing. Each device has its own three-dimensional reconstruction algorithms; there are wide inconsistencies in the grain and sharpness of the image, regardless of the voxel size.

Cone beam technology

Cone beam uses a beam of coned radiation that performs a single rotation (180 to 360 depending on the model) around the patient, using the same principle as panoramic radiography. The development of this type of scanner was made possible by manufacturing sensors with a large detection surface (Cotton et al, 2007; Patel et al, 2007). With the cone beam it is possible to obtain a volumetric image of an X-rayed object. The acquired volume is made up of voxels (which are a threedimensional pixels). It is then possible, using imaging software, to simultaneously explore this volume in a transverse, frontal or sagittal direction and to thus reveal structures that are not visible on a two-dimensional standard X-ray.

Cone beam generators

There are numerous models of cone beam available dedicated to dentistry (Master 3D, Picasso Duo, Picasso Trio, Illuma, Kodak 9000 Extraoral, Kodak 9500, Galileos, ProMax, i-Cat, SkyView, GXCB-500, Accuitomo, NewTom). The majority of systems run at less than 100 kVolts. Only a few models (i-Cat, NewTom) use higher voltage tubes that are reserved for radiologists. Each brand offers its own innovations in the ease of utilisation or ergonomic field. The current trend is to reduce the size of the devices so that they may easily find a place in a dental surgery. The majority of these devices can also be used as panoramic XDr Bertrand Khayat graduated from the University of Paris in 1982 and obtained his certificate in endodontics and his master of science in dentistry from the University of Washington in 1987. He maintains a private practice limited to endodontics. Dr Khayat has lectured internationally, he is also widely published and an active member of many international endodontic societies and associations. Dr Jean-Charles Michonneau qualified in 1999 and obtained his certificated in endodontics in 2001 from the University of Brussels. He is currently in private practice limited to endodontics in Paris, France.

Specific problems
Crowns or any other metal element in the mouth cause many artifacts during the acquisition of the threedimensional image due to the absorption of the X-ray beam. The nature of the metal leads to great variations in the quality of the image. The alteration of the image is slightly lower with the cone beam than with the conventional scanner. In endodontics, it is common to examine teeth with posts and prosthetic restorations and artifacts produced by metal limit the image reading. Sometimes interpretation even becomes impossible (Figure 1a). The computer process used by the cone beam should mitigate against this problem (Zhang et al, 2007). Manufacturers are actively working on this aspect of image processing which is at present the main shortcoming of three-dimensional imagery. Currently, Planmeca is the first to adopt image processing software for their cone beam Promax, which minimizes the effect of metallic artifacts (Figures 1b and 1c).

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1a Figure 1a: Cross section showing many metal artifacts due to prosthetic restoration

1b Figure 1b: Section made with cone beam Promax (Planmeca) without any specific image processing (arrow)

1c Figure 1c: The same section after computer processing using Planmeca software. Metal artifacts are virtually missing and a greatly improved image is clearly seen (arrow)

2a Figure 2a: Standard radiograph of 24 showing no problems. The lamina dura seems intact and periapical bone trabeculae normal

2b

2c

Figures 2b and 2c: The two sections obtained through three-dimensional imagery clearly show significant apical lesions on the buccal root of 24, having already reached and perforated the buccal cortical bone

Cone beam technology: Conical beam radiation Volumetric image of the X-rayed object Exploration of this volume in three dimensions Definition of the image in voxels Processing of metal artifacts Radiation doses: Significantly lower than the conventional scanner Size range of the digital sensor Area of investigation may be limited to three to four teeth

Table 1: Size of voxels of different three-dimensional imagery devices

Promax

I-Cat

Newtom

Accuitomo Iluma

Optimised conventional scanner 0.25

Size of Voxels in mm

0.15

0.125-0.4 0.15-0.3

0.125

0.093

Table 2: Comparisons of radiation doses of different radiographic examinations

Standard dental X-ray Relevance Cone beam in endodontics: Assessment of the size and location of periapical lesions Assessment of anatomical structures Visualisation of the root canal system Visualisation of perforations and radicular resorption Diagnosis of fractures Cone Beam Standard panoramic X-ray Medical scanner

4-6 Sv 10-15 Sv 300-1300 Sv 50-250 Sv

Radiation dosage
The dose of radiation actually received by the patient during a conventional scan or cone beam is difficult to measure. Modern scientific data provides confusing and contradictory results, making comparison between models difficult. However, it is necessary to give some reliable information to patients and staff

users. The final aim is to estimate the dose received by each patient, the efficient dose (Gibbs, 2000). The latter measures the impact on biological tissues following radiation. It is the dose absorbed by the patient, multiplied by a tissue factor related to the irradiated body. The effective dose is measured in Sieverts.

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Figure 3a: Standard radiograph highlighting a significant periapical lesion on 11 and 12. The lateral incisor is necrotic (cold and electric pulp test). The possible involvement of the central incisor can not be seen on this image Figure 3b: Cross section showing the extent of the lesion at the the apex of 12. The presence of cortical buccal bone in contact with 11 is clearly seen indicating that this tooth is not involved. Only endodontic treatment of tooth 12 is required

3a

3b

Figure 4a: Standard radiograph Figure 4b: Magnified image of the large apical area tooth 22 showing a large lesion the size of which is difficult to assess Figures 4c, 4d, 4e and 4f: Cross sections at different levels showing extensive destruction of the palatal and buccal cortical bone extending to the floor of the nasal cavity

4a 4c 4d

4b 4e 4f

Effective dose = dose absorbed by the x patient tissue factor At the moment it is difficult to establish an accurate comparison between X-ray examinations (Table 2). Only orders of magnitude can be expressed (Gijbels et al, 2005; Ludlow et al, 2006; Mah et al, 2003; Ngan et al, 2003; Tsiklakis et al, 2005). Indeed, the dose received by the patient can only be based on the size of the examined area. A cone beam examination on a section of three teeth will give less radiation than two complete arches. The use of a
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high voltage generator coupled with latest generation digital sensors helps limit the effective cone beam dose.

The area of investigation

It is important to distinguish the size of the digital sensor with the area under investigation. The classic models (ProMax or I-Cat) have extended sensors necessary for mandibular or maxillary acquisition but also offer the possibility of reducing the radiographic dose in a specific area. By reducing the field, the effective dose decreases

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Figure 5a: Standard radiograph of 26 clearly showing a periapical lesion on the mesiobuccal root which appears in contact with the sinus floor Figure 5b: The front section shows a boney wall isolating the sinus from the lesion Figure 6a: Standard radiograph of 45 with apical lesion in close proximity to the mental foramen Figure 6b: Frontal section. The periapical lesion is in direct contact with the mental foramen making endodontic surgery impossible Figure 7a: Standard radiograph of a lateral incisor with atypical anatomy difficult to assess Figure 7b: Cross section of this lateral incisor showing two distinct roots. The contour of each root is clearly identified and treatment can be safely undertaken Figure 8a: X-ray of 16 with periapical lesion on the mesial root. Endodontic treatment seems quite satisfactory Figure 8b: Identification on cross section of a second untreated mesiobuccal root canal (arrow)

5a

5b

6a

6b

7a

7b

8a

8b

9b

9a

Figure 9a: The incisors had conventional endodontics on two separate occasions followed by apical surgery but without any improvement clinically or radiographically Figure 9b: Cross section reveals a dual root canal system on 22, explaining the persistence of the periapical lesion (arrow) Figure 9c: Sagittal cross section of 22. Only the buccal canal has been identified and addressed despite multiple interventions. The palatal canal (arrow) has its own apical foramen which has been completely missed during endodontic surgery

9c

10b

Figure 10a: Standard radiograph of 21. A horizontal fracture line seems visible in the cervical third Figure 10b: Cone beam image in transverse view showing a vertical fracture whose prognosis is very unfavorable 10a

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without any image degradation. A new generation of cone beam working only with a reduced sensor size has appeared on the market (Illuma). These new devices offer the same benefits and image definition near to the conventional cone beam at a much lower cost. They limit the investigation zone to a restricted area (three or four teeth) which is sufficient for endodontics. causes of endodontic diseases through three-dimensional exploration of the root canal system. It is possible to check the quality of obturation and the possible presence of an untreated canal. Anatomical complexities (C-shape lower molars, multiple canals in lower premolars, dual canal systems on upper incisors) are mapped to the source of an apical lesion (Figures 8a, 8b and Figures 9a, 9b and 9c). Perforations and stripping of the root during the preparation for a post are also identifiable using the cone beam. The presence of the metal may actually make the interpretation of the image more difficult, even impossible. External and internal resorption can make endodontic treatment very challenging. It is impossible to measure the outline and extent of resorption on standard images (Gartner et al, 1976). Three-dimensional imaging provides a more detailed picture of the resorptive defect and helps to refine the diagnosis. Resorptions are in most cases diagnosed too late, affecting the prognosis of the tooth.

Cone beam in endodontics

Identification and assessment of endodontic lesions With the cone beam it is possible to view lesions that intraoral periapical radiography does not show. The projection of different bone structures on traditional X-ray film (thick cortical bone, zygomatic arch) makes diagnosis sometimes uncertain depending on the location of the problem, notably palatal roots. Very small lesions go unnoticed on a conventional image (Figures 2a, 2b and 2c). Bender and Seltzer (1961) have shown that intra-oral X-rays do not reveal the presence of periapical changes if the cortical bone is not affected (Lofthag-Hansen et al, 2007; Nakata et al, 2006). Cone beam provides precise information on the extent, shape and location of periapical lesions (Figures 3a, 3b and Figures 4a, 4b, 4c, 4d, 4e and 4f).

Diagnosis of fractures
Tooth fractures, except in cases of trauma, are generally due to mechanical overload. It used to be thought that they occurred on heavily restored teeth or teeth with large posts. This is not corroborated in the scientific literature. Even teeth with minimal restorations can fracture if the occlusal stress is excessive. Without precise clinical and radiological examination, the diagnosis of vertical root fracture is difficult (Kositbowornchai et al, 2001). Indeed, the fracture line is often located in the major axis of the tooth and passes unnoticed on a standard image. With the cone beam radicular fractures can be clearly seen regardless of their location (Figures 10a and 10b). Unfortunately, fine vertical cracks, which are much thinner than fractures, are not visible on cone beam images. Microscopic examination of the root surface, thorough periodontal probing and percussion tests are necessary to establish an accurate diagnosis.

Anatomical structure and evaluation of related lesions of endodontic origin

Different anatomical structures can be in contact with lesions of endodontic origin. The presence of a periapical lesion in direct contact with the maxillary sinus may cause discharge, unilateral nasal symptoms and headaches. The Schneiderian membrane becomes thicker and light through the sinus becomes opaque. Cone beam imaging allows the practitioner to identify if there is a dental origin of the chronic sinusitis (Figures 5a and 5b). Lesions may be near nerve structures that will need protection during any endodontic treatment, either conventional or surgical. With the precise analysis of the scanner images a decision can be made whether surgery is feasible or not. The mental foramen (Figures 6a and 6b) and inferior dental nerve are clearly identifiable using the cone beam (Velvart et al, 2001). If surgery is contemplated, it may be approached with a maximum of anticipation and caution in risk areas (Tsurumachi, Honda, 2007).

Conclusion
The cone beam seems to have eliminated many of the initial flaws of the medical scanner. The apparatus is more compact, more convenient to use and meets the standards of use in a dental practice. The acquisition of a threedimensional image is rapid with little additional radiation to the patient. The volume obtained through adapted software allows us to explore each area in all dimensions. In endodontics, the cone beam has become a valuable tool to refine diagnosis and anticipate potential complications in treatment. The resolution of the latest equipment and especially processing after acquisition improve the quality of the image. It is now possible to view the root canal system of each tooth and effectively eliminate most metal artifacts. It would be desirable in the near future to analyze finer structures such as cracks, by improving the definition of the cone beam image.

Analysis of root canal anatomy

The clinical evaluation of root canal anatomy is still mostly limited to an evaluation of standard radiographic images. Even though many studies on extracted teeth have provided precise information on the anatomy of each tooth (Vertucci, 1984; Weine, 1998), nevertheless there are many variations (upper premolar with three roots, C-shape lower second molars) that can be evaluated thanks to the cone beam. The resolution obtained by the latest cone beam models enable us to see with more precision the complexity of root canal anatomy. The shape of the roots, their exact numbers and the position of each canal are clearly identifiable. It is possible to precisely locate root canal entrances before endodontic treatment (Figures 7a and 7b).

References
For a full list of references please contact the editor at siobhan.lewney@fmc.co.uk. Z

Diagnosis of failures and complications

The clinical and radiological examinations traditionally performed on treated teeth provide little information on possible reasons for failure. It is possible to understand the
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Acknowledgment
This article has been reprinted with kind permission from Realites Cliniques.

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