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By Bruno Azevedo, D.D.S., M.S., and William C. Scarfe, BDS, FRACDS, M.S.

This special feature article highlights an important session taking place during AAE20:

D-7 – CBCT Imaging for Endodontics: The Good, the Bad and the Ugly

Cone Beam Computed Tomography (CBCT) has become an indispensable diagnostic imaging tool in clinical endodontics. In particular, high resolution limited field of view 3D imaging volumes of the jaws provide endodontists with greater diagnostic accuracy for tooth and root morphology and both tooth and bone related pathology when compared to regular intraoral digital 2D imaging. Because the use of CBCT imaging provides clinicians with a greater degree of confidence in detection of anatomic variations and pathology, it acts as an important clinical decision support tool in that it provides valuable information on when to treat, how to treat and, just as importantly when not to treat. Like any adjunctive diagnostic technology, CBCT has opportunities to present “The Good, The Bad, and The Ugly” sides of diagnostic imaging.

“The Good” – CBCT imaging is emerging as the scaffold for upcoming technologies such as 3D printing, dynamic navigation and surgical guides and is being applied to better understand the healing process associated with previously endodontically treated teeth.  The American Association of Endodontists (AAE), in conjunction with the American Association of Oral and Maxillofacial Radiology (AAOMR), have developed and recently updated a position statement on the use CBCT imaging in endodontics providing evidence based clinical practice situations in which 3D imaging can be considered as the preferred imaging modality before, during and after endodontic therapy.  Currently the position statement does not address best practices involving technical issues such as acquisition parameters and image display settings for optimizing image quality and maximizing the diagnostic capabilities of available CBCT units.

“The Bad” – CBCT imaging has a positive impact on patient care, however, this imaging modality has certain limitations. These shortcomings result from the introduction of specific artifacts on CBCT images introduced because of the very nature of CBCT acquisition protocols, differences in volumetric reconstruction and the presence of high density dental materials such as endodontic filling materials, intracanal posts, dental implants and different types of dental restorations. Understanding the clinical impact of these limitations on reducing image quality can help clinicians take action on mitigating these effects, improving image quality to make informed clinical decisions.

“The Ugly” – Perhaps the most neglected aspect of CBCT imaging is the role of the clinician in understanding the importance of “The Bad” and in developing a systematic process for navigating a CBCT volumetric dataset to optimize interpretation of the images. To maximize the use of this imaging technology, endodontists must have an in-depth knowledge and active role in each phase of CBCT imaging workflow which includes four sequential pillars: acquiring the data, correcting the data, exploring the data and reformatting the data.  It is important to have an understanding on how to produce the best images that are appropriate for specific diagnostic tasks whether they be for the identification of root canal anatomy, detection of root fractures or periapical or peri-radicular pathology.

This interactive case-based presentation will walk clinicians through a unique systematic approach to identify key elements and techniques necessary to improve or optimize image quality and diagnosis in endodontics.  Each phase of the CBCT imaging work flow will be explained in detail. In the CBCT acquisition phase, we will stress the role of understanding and modifying exposure parameters according to specific diagnostic questions to achieve consistently “Good” quality images, independent of CBCT device.  In the data correction phase, we will teach you how to recognize undesirable imaging artifacts such as noise, beam hardening and booming artifacts and demonstrate how software can help users reduce these untoward effects. Using clinical cases, we will demonstrate the effect of task specific enhancement filters and discuss in which clinical scenarios should they be applied. In the exploring data phase, we will provide insights into new hardware and software advances that will fundamentally change how we display and interact with CBCT volumes. Finally, in the data reformatting phase, we will discuss the use of task specific 3D rendering and the impact of newly developed realistic 3D rendering for endodontic diagnosis – this will truly amaze you. This presentation will provide you with important tools to take full advantage of the important benefits offered by CBCT imaging.

Click here to learn more about this session and its speakers!