**4.3 Diagnosis and treatment of dento-alveolar trauma**

Most maxillofacial traumatic injuries involve only teeth (50%) or teeth and adjacent soft tissue (36%) while those affecting the alveoli are 13.6% remaining [30]. Unfortunately, periapical radiography has low sensitivity for the diagnosis of minimal displacements of teeth, alveolar or root fractures, however CBCT has the advantage that it is more comfortable for the traumatized patient; extraoral scan generates a multidimensional image avoiding the need for multiple intraoral radiographs. Bernardes et al. in 2009 compared, retrospectively, conventional periapical radiographs and CBCT images in 20 patients with suspected root fractures and found that CBCT was able to detect fractures in 90% of patients, while radiography could only detect fractures in 30–40% of patients. In conclusion, they reported that CBCT was an excellent complement to conventional radiography in the diagnosis of root fractures [31].

### **4.4 Identification of the apices of the teeth in relation to anatomical structures**

Conventional radiographs do not always allow for the evaluation of the spatial relationship of roots with their surrounding anatomical structures [32]. This is important in the context of surgical planning and treatment [21]. Radiological identification of the position of the roots and their apices against structures vitals such as the maxillary sinus or the dental canal is essential for pre-surgical evaluation for endodontic microsurgery and to prevent injury during root canal filling. Velvart et al. studied 55 patients with 44 lower molars and 6 lower premolars, which had been referred for apical surgery due to persistent periapical areas.

**Figure 3.** *(a) Periapical radiography and (b) CBCT scan of the same lesions.*

CBCT and periapical radiography were performed to identify these lesions, and concluded that the root canal system could be identified in 3 cases with normal radiography, but it was identified in all cases with CBCT and CBCT was also able to quantify the amount of cortical and spongy bone and the three-dimensional extent of the lesion [33]. (**Figure 4a** and **b**).

Rigolone et al. studied 43 upper first molars using CBCT for a possible microsurgical treatment of the palatine root and concluded that this method could provide enough information for a minimally invasive microsurgical technique through a vestibular access instead of a palatal access approach [34]. Low et al. in 2008 evaluated 37 premolars and 37 molars, derived for endodontic surgery in the upper jaw and verified that CBCT was able to identify 34% more lesions than periapical radiography; this detection was influenced by the proximity of the apices to the floor of the maxillar sinus and it was more difficult in

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fracture [21].

**Figure 4.**

**4.5 Identification of root resorption**

as osteoclasts, odontoclasts and dentinoclasts.

case of resorption [35]. (**Figure 5a, b** and **c**).

*Applications of CBCT in Endodontics*

*DOI: http://dx.doi.org/10.5772/intechopen.89956*

upper second molars. CBCT was also able to identify sinus membrane thickening, expansion of lesion in maxillary sinus, and apico-marginal communications while periapical radiographs not. These are important pre-surgical markers that may indicate possible surgical complications, oral antral fistula and vertical root

*The CBCT scan allows a diagnosis and treatment plan in all planes. (a) Sagital view and (b) Coronal view.*

Root resorption is the loss of dentin or cement as a result of osteoclastic activity. The resorption can be classified according to its location in internal or external. The cells responsible for resorption, whether internal or external, have been described

Internal root resorption occurs exclusively as a result of pulp inflammation. Until very recently, the diagnosis of internal or external resorption defects has been limited to the information obtained from conventional radiography techniques. Currently, the use of CBCT is used in the planning of diagnosis and treatment of a

Accurate identification is essential to ensure both correct treatment and management as it differs depending on the type of resorption. Gartner et al. described the guidelines to differentiate the types of resorption and the use of *Oral Diseases*

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**Figure 3.**

of the lesion [33]. (**Figure 4a** and **b**).

*(a) Periapical radiography and (b) CBCT scan of the same lesions.*

CBCT and periapical radiography were performed to identify these lesions, and concluded that the root canal system could be identified in 3 cases with normal radiography, but it was identified in all cases with CBCT and CBCT was also able to quantify the amount of cortical and spongy bone and the three-dimensional extent

Rigolone et al. studied 43 upper first molars using CBCT for a possible microsurgical treatment of the palatine root and concluded that this method could provide enough information for a minimally invasive microsurgical technique through a vestibular access instead of a palatal access approach [34]. Low et al. in 2008 evaluated 37 premolars and 37 molars, derived for endodontic surgery in the upper jaw and verified that CBCT was able to identify 34% more lesions than periapical radiography; this detection was influenced by the proximity of the apices to the floor of the maxillar sinus and it was more difficult in

**Figure 4.**

*The CBCT scan allows a diagnosis and treatment plan in all planes. (a) Sagital view and (b) Coronal view.*

upper second molars. CBCT was also able to identify sinus membrane thickening, expansion of lesion in maxillary sinus, and apico-marginal communications while periapical radiographs not. These are important pre-surgical markers that may indicate possible surgical complications, oral antral fistula and vertical root fracture [21].

#### **4.5 Identification of root resorption**

Root resorption is the loss of dentin or cement as a result of osteoclastic activity. The resorption can be classified according to its location in internal or external. The cells responsible for resorption, whether internal or external, have been described as osteoclasts, odontoclasts and dentinoclasts.

Internal root resorption occurs exclusively as a result of pulp inflammation. Until very recently, the diagnosis of internal or external resorption defects has been limited to the information obtained from conventional radiography techniques. Currently, the use of CBCT is used in the planning of diagnosis and treatment of a case of resorption [35]. (**Figure 5a, b** and **c**).

Accurate identification is essential to ensure both correct treatment and management as it differs depending on the type of resorption. Gartner et al. described the guidelines to differentiate the types of resorption and the use of

**Figure 5.**

*(a) Periapical radiography of teeth affected by a root resorption, (b and c) CBCT scan of the teeth affected by a root resorption.*

2D radiographic techniques with a parallelizer was postulated as the method to differentiate internal resorption from external. However, conventional radiography does not represent the lesion, being unable to identify its true size,

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**Figure 6.**

*Cyst lesion and adjacent tissues affected.*

*Applications of CBCT in Endodontics*

*DOI: http://dx.doi.org/10.5772/intechopen.89956*

location and access [36]. The diagnostic advantages of CBCT lie in the ability of its software to access the most favorable orthogonal views related to the specific spatial vision and the ability to reproduce an accurate three-dimensional image of the lesion in relation to the root anatomy. Cohenca et al. in 2007 concluded that CBCT was extremely useful for diagnosing the degree of root resorption, determining subsequent treatment. Internal root defects, such as resorption, can perforate the external surface, and this may not be detectable by conventional radiographic techniques. The test should be done during diagnosis and treatment planning. The main limitation of conventional radiographic techniques is that a two-dimensional image can only provide limited clinical information regarding three-dimensional structures. The CBCT provides additional information about the location and nature of the root. With the low effective doses, and the relevant additional information provided, the use of CBCT scanners is justified in the management of complex endodontic problems. The results of images obtained by CBCT can modify the treatment planning, as well as the techniques that can be

used during a surgical or non-surgical endodontics [37, 38].

**4.6 The diagnosis of cystic lesions and non-endodontic pathology**

The diagnosis of cystic lesions is very important because there is controversy about these lesions and the curation without surgical treatment, since cysts can only be diagnosed histologically, which needs surgical excision. Different studies have tried to differentiate between granuloma and cysts through radiographs, based on the different densities of the contents of the cavity. Simon et al. in 2006 using CBCT found that the diagnosis coincided with the histological examination in 13 of the 17 cases studied [39]. However, Rosenberg et al. in 2010 about 45 cases, concluded that the diagnosis did not could be confirmed with CBCT [40]. Other studies should be

#### *Applications of CBCT in Endodontics DOI: http://dx.doi.org/10.5772/intechopen.89956*

*Oral Diseases*

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**Figure 5.**

*a root resorption.*

2D radiographic techniques with a parallelizer was postulated as the method to differentiate internal resorption from external. However, conventional radiography does not represent the lesion, being unable to identify its true size,

*(a) Periapical radiography of teeth affected by a root resorption, (b and c) CBCT scan of the teeth affected by* 

location and access [36]. The diagnostic advantages of CBCT lie in the ability of its software to access the most favorable orthogonal views related to the specific spatial vision and the ability to reproduce an accurate three-dimensional image of the lesion in relation to the root anatomy. Cohenca et al. in 2007 concluded that CBCT was extremely useful for diagnosing the degree of root resorption, determining subsequent treatment. Internal root defects, such as resorption, can perforate the external surface, and this may not be detectable by conventional radiographic techniques. The test should be done during diagnosis and treatment planning. The main limitation of conventional radiographic techniques is that a two-dimensional image can only provide limited clinical information regarding three-dimensional structures. The CBCT provides additional information about the location and nature of the root. With the low effective doses, and the relevant additional information provided, the use of CBCT scanners is justified in the management of complex endodontic problems. The results of images obtained by CBCT can modify the treatment planning, as well as the techniques that can be used during a surgical or non-surgical endodontics [37, 38].
