Review Article

Cone-beam computed tomography and its applications in

dentistry
Daniel Silas Samuel1, Revathi Duraisamy1, M. P. Santhosh Kumar2*

ABSTRACT

It has been more than a century since William Conrad Roentgen first discovered the X-ray. Radiology has transformed itself
from scientific curiosity to a medical and dental necessity. The evolution of radiographs from periapical to extraoral imaging,
and cephalometric, and panoramic radiography has heralded major progress in dental radiology, providing clinicians with a
single comprehensive image of the jaws and maxillofacial structures. Even though radiograph is useful in certain ways, it has
its own pros and cons. Exposure to X-ray beam radiation for prolonged period can result in the development of cancer and
other adverse effects. Cone-beam computed tomography (CBCT) is an advanced medical imaging technique that generates
three-dimensional (3-D) image at a lower cost and absorbed dose compared to that of conventional CT. This technique is
based on a cone-shaped X-ray beam centered on a two-dimensional (2-D) detector that performs one rotation around the
object, producing a series of 2-D images. These images are reconstructed in 3-D using a modification of the original cone-
beam algorithm developed by Kamp et al., in 1984. Interest in CBCT from all fields of dentistry has been unprecedented,
as the results of a 3D visualization provided improved interpretation, diagnosis, and treatment planning. It also showed a
tremendous impact in dental implant treatment planning, giving the arch and ridge configuration, and location of the nerve
and maxillary sinus before the surgery, thereby decreasing surgical uncertainty. Many innovative software programs are
useful in making customized surgical guides, virtual models, and laser-generated resins for treatment planning. This article
describes CBCT generations, advantages, disadvantages, and the various applications of CBCT in dentistry.

KEY WORDS: Applications, Computed tomography, Cone-beam computed tomography, Craniofacial surgery, Dental
implantology, Oral and maxillofacial pathology, Oral and maxillofacial surgery

INTRODUCTION It is very useful in the field of dental implantology,

oral surgery, orthodontics, endodontics, sleep apnea
Cone-beam computed tomography (CBCT) is a management, temporomandibular joint (TMJ)
modern radiographic imaging technique which is used disorders, and periodontics.
to take three-dimensional image of an object. CBCT is
a diagnostic tool that has helped dentists in diagnosis DENTAL APPLICATIONS OF CBCT
and treatment planning in the field of dentistry.[1] It
is useful in almost every aspect of dentistry due to Dental Implantology
its accuracy, but the exposure to radiation is more in For the overall success of implant treatment and to avoid
this technique. CBCT presents as a separate C-arm post-operative implant complications, implantologists
to CT imaging [Figure  1]. CT uses a comparatively should have three-dimensional (3D) information of
less expensive radiation detector than conventional bone volume and topography before implant placement.
CT imaging. Table  1 describes about the various Presurgical assessment of the implant site by imaging
generations of CBCT. technique thus allows for the accurate assessment of
the amount of bone volume available, bone density, and
proximity to anatomical structures. The buccolingual
Access this article online ridge pattern cannot be viewed on 2D radiographs, but
Website: jprsolutions.info ISSN: 0975-7619
CBCT provides the advantage of identifying the type of
alveolar ridge pattern present.[2]

1
Department of Prosthodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha
University, Chennai, Tamil Nadu, India, 2Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha
Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr. M. P. Santhosh Kumar, Department of Oral and Maxillofacial Surgery, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Velappanchavadi,
Chennai - 600 077, Tamil Nadu, India. Phone: +91-9994892022. E-mail: [email protected]

Received on: 18-08-2018; Revised on: 22-09-2018; Accepted on: 25-10-2018

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 Daniel Silas Samuel, et al.

Table 1: Generations of CT
Generations Detectors Type of beam Tube detector Duration of scan
of CT movements
1st generation One Pencil X‑ray beam Translate‑rotate 25–30 min
2nd generation Multiple Fan‑shaped X‑ray beam Translate‑rotate <90 s
3rd generation Multiple, originally 288, newer Fan‑shaped X‑ray beam Rotate‑rotate Approximately 5 s
ones used 700 arranged in an arc
4th generation Multiple arranged in an outer Fan‑shaped X‑ray beam Rotate‑fixed Few seconds
ring fixed
CT: Computed tomography

There are three types of computer-generated surgical

guides: Tooth supported, mucosa supported, and
bone supported. Tooth-supported guides are mostly
used in partially edentulous cases. This surgical
guide is designed to rest on other teeth in the arch
for accuracy, for guide fit. Mucosal-supported guides
are used primarily in fully edentulous cases and are
designed to rest on the mucosa. Accurate interarch
bite registrations are of utmost importance when
Figure 1: Cone-beam computed tomography machine using these guides to assure accurate surgical guide
positioning and placement of securing screws/pins
It can be used to identify the quality of bone at the before the placement of implants. Bone-supported
implant sites. The term “bone quality” is commonly guides can be used in partially or fully edentulous
used in implant treatment based on implant success cases, but they are used in fully edentulous cases
and failure. Bone quality is not only a matter of mineral which show significant ridge atrophy and good seating
content but also of structure. Bone quality comprises of mucosa-supported guides are questionable.[7]
factors such as skeletal size, bone architecture, the 3D
orientation of the trabeculae, and matrix properties.[3] Oral and Maxillofacial Pathology
Implant placed in poor-quality bone of thin cortex and Conventional CT is used routinely in the diagnosis of
low-density trabeculae (Type  4 bone) has a higher maxillofacial pathology. Three- dimensional imaging
chance of failure compared with the other types of of cysts and tumors of the maxillofacial region can
bones. This low-density bone is often found in the give the surgeon the vital information necessary for
posterior maxilla and it has high chances of failure planning surgery. The volumetric analysis can help
when placed at this region. Bone density can be anticipate the need for and volume of a potential graft
expressed in terms of Hounsfield units. With more for reconstruction.[8]
advanced CBCT software and methods, it should be
possible to determine bone densities at implant sites. TMJ Disorders
Thus, CBCT provides a subjective assessment of bone
The imaging offered by current CBCT machines
quality and not an objective assessment.[4]
has been shown to provide a complete radiographic
CBCT-guided implant surgery is the widely used evaluation of the bony components of the jaw. The
modality in dental implantology nowadays. With resulting images are of high diagnostic quality. CBCT
CBCT the type and size of the planned implant, shows significantly reduced radiation dose and cost
its position within the bone, its relationship to the compared with conventional CT.[9]
planned restoration and adjacent teeth or implants,
and its proximity to vital structures can be determined Craniofacial Surgery
before performing surgery.[5] Surgical guides are not CBCT allows better evaluation of dental age, arch
indicated for every case, and some indications are as segment positioning, and cleft size compared with
follows: Three or more implants in a row, proximity to traditional radiography. Volumetric analysis promises
vital anatomic structures, questionable bone volume, to offer better prediction in terms of the morphology
flapless implant placement, multiple unit or full-arch of the defect, as well as the volume of graft material
restorations, with or without extractions, and immediate necessary for repair.[10] CBCT provides means to look
replacement. With the use of computer-guided implant and investigate these issues in depth.
surgical guides, this anatomic relationship can be
predictably established and considered before surgery. Evaluation of Impacted Teeth
Gutta-percha, barium sulfate, and lead foils have been The identification, treatment planning, and evaluation
used for the fabrication of surgical guides.[6] of potential complications of impacted teeth are greatly

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 Daniel Silas Samuel, et al.

improved through CBCT. The site evaluation becomes such as overextended root canal obturation material,
not only less invasive and less time-consuming but separated endodontic instruments, calcified canal
also gives a complete overview. Using CBCT to identification, and localization of perforations. It is also
locate and evaluate impacted third molars, cuspids used in diagnosis and management of dentoalveolar
and supernumerary teeth seem to make the surgical trauma, especially root fractures, luxation and/or
procedure more efficient and less invasive.[11] The displacement of teeth, and alveolar fractures. It is
adjacent structure against the area of interest can be useful in localization and differentiation of external
seen in three dimensions. The relationship of impacted from internal root resorption or invasive cervical
third molars to the mandibular canal, adjacent teeth, resorption from other conditions. CBCT is indicated
and cortical borders provides important diagnostic for presurgical case planning to determine the exact
information that can directly impact the outcome of location of root apex/apices and to evaluate proximity
surgery.[12] of adjacent anatomical structures.[15]

Orthodontics CBCT reduces the risk of canal perforation, missed

Three-dimensional model can be reliably adopted for canal anatomy, or morphology, thereby, greatly
orthodontic and orthognathic analysis and surgical increasing the chances for endodontic success and it
prediction. Extensive research is needed to differentiate is a precise modified canal staining and tooth clearing
the landmarks and relationships that this technology method to determine root canal morphology.
allows us to measure. CBCT machine can be adjusted
Dental Periapical Pathogenesis
to a small field of view specifically targeting an area
of interest compared to regular CT, thereby assuring The most common pathologic conditions seen in
X-ray beam limitation. The effective dose of radiation teeth are inflammatory lesions of the pulp and
ranges from 36.9 to 50.3 μSv and it records basic periapical origin. CBCT technology now provides
images in one rotation (scan time - 10–70 s), thereby the clinician to view the area in three different planes.
making it a better adjunct than CT with relevance to Lesions confined to cancellous bone with little or no
orthodontic diagnosis and treatment planning. The cortical plate erosion can be difficult to diagnose
effects on airway restriction can have profound effect with intraoral film. CBCT technology provides
on dentition, speech, and craniofacial development an area of gray values which aids in the diagnosis
making it important to diagnose early during growth of cysts versus granulomas. The higher detection
period. Airway space is better analyzed using CBCT. rates afforded by CBCT are like those reported for
It can be used to make customized brackets and wires conventional CT.[16]
for individual patients, in digital modeling after
Pedodontics
constructing a physical model and for determining
ideal site for mini-implant placement.[13] CBCT is used to evaluate morphological variations
and eruptive disturbances in the permanent teeth which
Endodontics occur as sequelae to trauma in their predecessors. It is
CBCT has been shown to display the periodontal also used to assess the extent of dilaceration, palatal
ligament space more accurately when compared displacement of crown, root resorption, localization of
to intraoral radiography, panoramic radiography, impacted tooth, and a gradual curvature in the apical
computerized radiography, and digital volume one-third of the root of permanent teeth following
tomography. In general, the use of CBCT in trauma to primary. It determines the close relationship
endodontics should be limited to the assessment and between root apex of primary and permanent tooth
treatment of complex endodontic conditions such as: germ which, in turn, explains the easy occurrences of
disturbances in permanent teeth.[17]
Identification of root canal system anomalies and
determination of root curvature, diagnosis of dental Periodontics
periapical pathogenesis in patients who present CBCT has been used to obtain detailed morphologic
with contradictory or non-specific clinical signs descriptions of bone that is accurate than those obtained
and symptoms, patients who have poorly localized through direct measurement with a periodontal probe.
symptoms associated with an untreated or previously CBCT provides accurate measurements of intrabony
endodontically treated tooth with no evidence of defects and allows clinicians to assess dehiscence,
pathogenesis identified by conventional imaging, and fenestration defects, and periodontal cysts. It can
in cases where anatomic superimposition of roots be used to assess the furcation involvement of
or areas of the maxillofacial skeleton is required to periodontal defects and allows clinicians to evaluate
perform task-specific procedures.[14] the postsurgical results of regenerative periodontal
therapy. CBCT is also helpful in identifying small
CBCT can be used for intracanal or post-operative osseous defects. Hence, CBCT is considered the
assessment of endodontic treatment complications superior most imaging modality in periodontics.[18]

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 Daniel Silas Samuel, et al.

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