BARTOSZ ERWIN SZTABIŃSKI
5th Year, Group 12th3D cone beam computed tomography as a main
diagnostic tool in everyday work of an odontologist-
a systematic review.
Master ThesisSupervisor :
Dr. Gediminas Skirbutis
INDIVIDUAL DEVELOPMENT PLAN FOR THE MASTER’S THESIS
Graduate student : Bartosz Erwin Sztabiński of the year 2019, and the group 12 of the integrated study program of Odontology.
Duration of studies from __________________till_________________
Supervisor Dr.Gediminas Skirbutis MT title: 3D cone beam computed tomography as a main diagnostic tool in everyday work of an odontologist - a systematic review.
MT annotation:
______________________________________________________________________________ ______________________________________________________________________________
Aim of the work: to establish if 3D CBCT can be a golden standard diagnostic tool in everyday
work of odontologist ?
Tasks of the work:
• Drawing a brief comparison between the effective radiation dosage between the radiological methods
• Analysing recent data about use of cone beam computed tomography in diagnostics methods • Deducing if 3D cone beam computed tomography can be a golden standard diagnostic tool
Schedule of the works
No. Description of MT task
Done/not done
(supervisor’s
evaluation and
signature)
1 Title selection
2018/09/01
Performance
deadline
2
Methods:
protocol and registration; eligibility
criteria; information sources; search,
study selection, data collection process;
data items; risk of bias in individual
studies; summary measures, synthesis
of results; risk of bias across studies;
additional analyses.
2018/10/30
3
Results:
Study selection; Study characteristics;
Risk of bias within studies; Results of
individual studies; Synthesis of results;
Risk of bias across studies; Additional
analysis.
2018/11/30
6
Introduction:
Rationale; objectives
2018/12/30
5
Discussion:
Summary of evidence; Limitations;
Conclusions
2019/01/30
4
Abstract:
Structured summary: Objectives; Data
sources; Study eligibility criteria;
Study appraisal and synthesis methods;
Results; Limitations; Conclusions and
implications of key findings;
Systematic review registration number.
2019/02/28
7 1
stversion of MT
2019/03/01
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY CLINIC OF PROSTHODONTICS
3D cone beam computed tomography as main diagnostic tool in everyday
work of an odontologist - a systematic review.
Master’s Thesis
The thesis was done
by student ……… Supervisor ……….
(signature) (signature)
………. ………
(name surname, year, group) (degree, name, surname)
………20... ……….20…….
(day/month) (day/month)
EVALUATION TABLE OF THE MASTER’S THESIS OF THE
TYPE OF SYSTEMATIC REVIEW OF SCIENTIFIC LITERATURE
Evaluation: ... Reviewer: ...
(scientific degree. name and surname)
Reviewing date: ...
N o.
MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partial ly No 1 Summary (0.5 point)
Is summary informative and in compliance with the thesis content and requirements?
0.3 0.1 0
2 Are keywords in compliance
with the thesis essence?
0.2 0.1 0
3
Introduction, aim and tasks (1 point)
Are the novelty, relevance and significance of the work justified in the introduction of the thesis?
0.4 0.2 0
4 Are the problem, hypothesis, aim and
tasks formed clearly and properly?
0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6
Selection criteria of the studies, search
methods and strategy (3.4 points)
Is the protocol of systemic review present?
0.6 0.3 0
7
Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language, publication condition, etc.)
0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11
Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
12
Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
13
Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to
be used in data synthesis, described? 0.2 0.1 0
14 Were the principal summary
measures (risk ratio, difference in means) stated? 0.4 0.2 0 15 Systemization and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of
exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents)
presented?
17
Are the evaluations of
beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to individual tasks?
0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their relevance indicated?
0.4 0.2 0
20 Are the limitations of the
performed systemic review discussed?
0.4 0.2 0
21 Does author present the
interpretation of the results?
0.4 0.2 0
22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and tasks of the Master’s thesis?
0.2 0.1 0
23 Are the conclusions based on the
analysed material?
0.2 0.1 0
24 Are the conclusions clear and
laconic?
0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements?
0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?
0.2 0.1 0
27 Is the scientific level of references
suitable for Master’s thesis?
0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years – at least 40%?
0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the analysed topic?
+0. 2
30 Practical Are the practical recommendations suggested and are they related to the received results? +0. 4 +0.2 0 Recommendations 31
Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?
+1 +0.5 0
32 Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysis presented?
+2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General requirements
Is the thesis volume sufficient (excluding annexes)? 15-20 pages (-2 points) <15 pages (-5 points)
34 Is the thesis volume increased
artificially?
-2 poi nts
-1 point
35 Does the thesis structure
satisfy the requirements of Master’s thesis?
-1 point -2 points
36 Is the thesis written in correct
language, scientifically, logically and laconically?
-0.5 point
-1 points
37 Are there any
grammatical, style or computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral,
and are the volumes of its structural parts balanced?
-0.2 point
-0.5 points
39 Amount of plagiarism in the
thesis.
>20% (not evaluated)
40
Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point
*Remark: the amount of collected points may exceed 10 points.
Reviewer’s comments:
Reviewer’s name and surname Reviewer’s signature
———————————————— ————————————————— 41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?
-0.2 point
-0.5 points
42 Are there explanations of the
key terms and abbreviations (if needed)?
-0.2 point
-0.5 points
43 Is the quality of the thesis typography (quality of printing, visual aids, binding) good?
-0.2 point
-0.5 points
TABLE OF CONTENTS
1. Abbreviations………..11
2. Summary………12
3. Introduction………13
4. Selection criteria. Search methods and strategy………16
5. Systematisation and analysis of data……….18
A. Diagnostics of early , secondary caries under permanent restorations………..18
B. Cone beam tomography in endodontics……….20
C. Cone beam tomography in periodontal assessment………21
D. Cone beam tomography in oral surgery and temporomandibular joint assessment…………22
E. Cone beam tomography in orthodontic evaluation……….23
F. Cone beam tomography in implantation treatment planning………..24
6. Discussion………..25
7. Conclusions………28
8. References………..29
ABBREVIATIONS
CBCT - cone beam computed tomography CB - cone beam
2D/3D - two/three dimensional CT - computed tomography
ALARA - as low as reasonably achievable Y - year
M - month P - patient
MB - mesiobuccal RC - root canal
IOR - intraoral radiograph
OS - oral surgery ORTH - orthodontics OPG - panoramic x - ray PAN - panoramic x -ray SCAN - scanography
TMJ - temporomandibular joint CR - case report
RA - review article
SUMMARY
AIM : to deduce if cone beam computed tomography can be a main diagnostic tool in everyday
work of the odontologist, by analysing recent scientific articles in order to establish its advantages and disadvantages in comparison to standard radiological methods.
Materials and methods : study was conducted by one investigator according to
PRISMA-Protocol. Studies were collected from PubMed and Research Gate, between June and December 2018. Articles were excluded during screening and eligibility due to non-English, non-human, older than 2014 . Leaving systematic reviews/case reports included.
Results : 3D Cone beam computerised technology (3D CBCT) offers three dimensional and more
complex imaging compared to conventional radiographic methods. It is an accurate tool for many clinical cases, with lower radiation doses than standard computerised tomography, and with newest technologies even with conventional panoramic X-ray.
This systemic review determined the clinical value of this imagining technique in everyday work of an odontologist. Factors considered in use 3D CBCT device include cost, time and amount of images required to generate and collect proper data , responsibility for its interpretation. Data sources for this review are scientific articles about usage of cone beam technologies, clinical cases and comparison between imagining methods, as well as newest technological advancement in the field of dental imagining.
Conclusions : cone beam computed tomography as a diagnostic tool showed great success in
everyday work of odontologists , due to broad spectrum of its use and high accuracy. CBCT has higher success rate in diagnostics than any other conventional methods. Even though, costs, and general lack of information about the technology occurs, in the future it could become a golden standard methods for providing any diagnosis and treatment planning.
Introduction :
In 1895 Sir Wilhelm Conrad Roentgen created the beginning of wonderful era for the history of the medicine - he discovered the X-rays. 14 days later, after the first publication of this phenomena , german dentist , Dr. Otto Walkhoff made the first picture of the teeth. This started a rapid progress in the diagnostics methods in the whole field of dentistry.
Till these days - X-ray , in many forms and techniques , is hold as a golden standard for dental practices. Although , diagnostic’s methods in passing years turned out to own few additional technologies. Three dimensional imaging evolved to meet the demands of the modern diagnostics. Cone beam computed tomography (CBCT) is an imaging method that allows three-dimensional view of hard and partially soft tissue structures in a proper accuracy.
In 1988, cone beam computerised tomography was introduced to dentistry.
CBCT is not a new concept and was originally used for radiotherapy and later for angiography cross sectional imaging.
Now-days CBCT plays a huge role in the diagnosis, identification and determination of the severity and complexity of diseases in the whole field of medicine.
However ,for the most of dental practitioners, the use of this technology has been limited - due to its costs, radiation dose considerations and availability. This review’s purpose is to improve understanding of advanced imagining techniques , provide deeper insight into cone beam technology and give recommendations of its use for every dental practitioner.
Can 3D CBCT be a golden standard in the daily base work of the odontologist ? General principles of working
Imaging in CBCT technology is achieved by using a rotating gantry to which an x-ray ionizing radiation source and detector are fixed. A pyramidal or cone-shaped source of radiation is directed through the middle of the area of interest , onto detector on the opposite side.
The x-ray source and detector rotate around a rotation fulcrum fixed within the center of the region of interest. During the rotation, multiple sequential planar projection images of the field of view are acquired in a complete or partial. [1]
This action differs from a traditional computed tomography , which uses a fan-shaped x-ray beam to acquire single image slices of the field of view, then each of the slices are incorporated into one piece achieving 3D view. CBCT imagining includes the entire field of view, though only one rotational sequence of the gantry is necessary to acquire data for 3D reconstruction. (Figure 1.[1])
Image production and field of view
Cone-beam computed tomography machines scan patients in three positions: supine, standing and sitting. The most preferable positioning unit is sitting, which decreases the problems of imagining for patients with disabilities, like eg. wheelchair patients.
The shape of the scan can be cylindric or spherical. Transformation of the x-ray beam limits radiation only to the region of interest. Field of view can be selected for each patient, based on disease presentation. (Table 1.)
Scan time and accuracy
CBCT acquires all images in a single rotation. Time for data set reconstruction, is longer than standard radiographic methods , in comparison to eg. panoramic x-ray, but it differed depending on field of view selection ,image resolution required , number images. It may range from 1 minute to 20 minutes (all segments together). Cone - beam imaging produces images with isotropic voxel resolution ranging from 0.4 mm to as low as 0.076 mm. Due to this , images achieve a level of spatial resolution accurate enough for measurement in maxillofacial applications where precision in all dimensions is important, such as implant site assessment and orthodontic analysis. [1]
Indications for application
Currently, cone-beam technology is used most commonly in the assessment of bony and dental pathologic conditions, preoperative assessment of impacted teeth, and implant placement. CBCT shows promising results in orthodontics 3D cephalometry, diagnostics of early secondary caries under permanent restorations or proximal and non cavitated caries, as well as in assessment of temporomandibular joint disorders. Cone beam is a natural fit for implant planning. It acquires undistorted position of crucial structures such as the inferior alveolar nerve or the maxillary sinus, and provides accurate bone quality assessment. In endodontics, you can see precise endodontic pathology and the accuracy even allows visualisation of the MB2 canals in upper molars prior to access. In periodontics , this technology allows you to see bone levels in three dimensions around a tooth and provides better choice of treatment planning. Also, cone bean technology has its uses in airway management, for sleep apnea and snoring patients, providing complex diagnostics and assessment of best treatment.
Figure 1. [1] Comparison of traditional CT(right) with CBCT (left). - What is Cone-Beam CT and
How Does it Work? - William C. Scarfe, BDS, FRACDS, MSa,*, Allan G. Farman, BDS, PhD, DSc, MBA
Table 1. Categorization of CBCT systems according to the available field of view or selected scan
Selection criteria of articles. Search methods and strategy.
This systematic review was conducted in accordance with the PRISMA-P (Preferred
Reporting Items for Systematic review and Meta-Analysis Protocols) recommendations to
analyse and determine whether or not the cone beam computed tomography can be a golden standard for everyday work of the odontologist.
Eligibility criteria:
This review extracted data independently as a scientific article based research.
The articles use as a reference and information provider were dated between the years of 2014-2018. Publication status of articles is published and submitted.
Inclusion criteria:
The main key words used in the research process were : 3DCBCT, odontology, diagnostics tools, computed tomography , cone beam, dentistry. Sources of the reviews were : medical sciences webpages and data bases. Language of the extracted information was english.
Exclusion criteria:
1. Reviews with language different than English were excluded 2. Studies without CBCT diagnostic test were excluded.
3. Reviews older than 2014 were excluded. 4. Unpublished articles were excluded
Search strategy:
The search of publications was performed by one investigator, who selected, screened, and verified the collected material ́s eligibility. This search was undergone from June till December 2018, and was conducted through Pubmed, Research Gate, To fully access these databases and gather full text articles, the usage of LSMU ́s EZPROXY was necessary. In addition, the following key words and their different combinations were used 3DCBCT, diagnostics tools, dentistry, The search was later on complemented by a manual review of articles and references of the gathered material. Further on, the final articles collected for systematic analysis was then double - checked by the supervisor (Dr. Gediminas Skirbutis).
Risk of bias :
Among limitations, the risk of bias has not been fairly paid attention to, in few of the selected studies. This should be taken in consideration while reading this systematic review.
PRISMA Flow Diagram
Figure 2. PRISMA flow diagram.
Studies included in literature review (n = 19 ) Studies included in systematisation and analysis (n = 13) Full-text articles assessed for eligibility
(n =25 )
Records excluded (n = 10 ) Records screened
(n =35 )
Records after duplicates removed (n = 35 )
Additional records identified through ResearchGate (n = 20 ) Id entif ic ation El igi b il it y Inc lu de d Sc re ening
Records identified through PubMed (n = 40 )
Full-text articles excluded,
SYSTEMISATION AND ANALYSING OF DATA
6A. Cone beam in diagnostics of caries
In the study from 2017, 128 human premolar and molar teeth that were extracted for periodontal or orthodontic reasons. 64 teeth were with dentine caries (16 premolars with occlusal caries, 16 premolars with interproximal caries, 16 molars with occlusal caries and 16 molars with interproximal caries) and 64 control teeth were without caries (32 premolars and 32 molars). Teeth were cleaned of calculus and debris, disinfected in 2% sodium hypochlorite solution for 20 min and stored in distilled water. [2]
For imaging procedures, each tooth was placed in the appropriately prepared maxillary and mandibular pre- molar and molar sockets of a dry skull along with its mandible. The dry skull along with its mandible was covered with 2cm red wax as a soft-tissue equivalent material. All teeth were randomly placed in the alveolar sockets in groups of 16 in contact. The cross-sectional aspects of each restored tooth were randomly evaluated for the presence/absence of caries under restorations and were scored using a 5-point scale as follows: 1 5 caries definitely present; 2 5 caries probably present; 3 5 uncertain–unable to tell; 4 5 caries probably not present; and 55caries definitely not present. [2]
Study has shown very good results in imaging of the caries , and no significant difference in comparisons of different medical displays and CBCT machines. Dentists are often asked to assess caries under restorations in the available CBCT images taken for other reasons.
Study suggests that when evaluating images for the detection of recurrent caries , using CBCT with dedicated software and medical greyscale monitor would increase the accuracy of correct diagnosis. Observers performed better in detection of recurrent caries when assessing composite restorations than when assessing amalgams, due to appearance of artefacts in the imaging of amalgam restorations.
Figure 3. [3] Cross-sectional CBCT images- (a) amalgam restoration without caries, (b) composite
restoration without caries, (c) amalgam restoration with recurrent caries, (d) composite restoration with recurrent caries, (e) amalgam restoration with beam-hardening artefact.
In this study of “ Priyanka Ramesh Vedpathak et al., Use of CBCT in Detecting Caries Under FDP “ the inclusion criteria was six extracted carious permanent teeth (Tooth no. 11, 12, 23, 16, 26, 47 ) with caries that extended to dentin and the pulp cavity and cavity walls all along the cervical, middle and occlusal third of the crown. [11]
All the selected teeth were without any restoration and got extracted because of extensive caries and mobility. Extracted teeth were then cleaned and kept in distilled water for 24 hours at 37oC. During teeth preparation, the caries cavity was filled with wax to a level in line with the preparation outline making it a full crown structure.[11]
Cast with all crown specimens were put into water in order to imitate oral soft tissues. Each specimen was then scanned with CBCT for evaluation of the secondary caries under fixed prostheses. [11] In results CBCT outperformed intraoral radiography in detection of recurrent caries under restorations. CBCT enables the detection of grade 6 caries under the crowns of all four materials (full metal, metal ceramic, full ceramic, metal acrylic ). The radiopacity of the restorative material have a significant effect on accuracy with conventional but not with advanced three dimensional radiographic techniques. CBCT scans taken for other reasons can be used as a post- treatment diagnostic technique for detecting caries under fixed dental prostheses. Since the routine 2D radiographic techniques cannot detect caries under fixed metallic dental prostheses, there is a need for CBCT (3D) radiographic techniques to detect such carious lesions.
Figure 4. [4] Cross sectional images of CBCT scan. “Ramesh Vedpathak et al., Use of CBCT in
Detecting Caries Under FDP “
6B.Cone beam technology in endodontics.
In the study of year 2018, “Cone-beam Computed Tomography Compared with Intraoral Radiographic Lesions in Endodontic Outcome Studies “ by Anita Aminoshariae, DDS, MS,James C. Kulild, DDS, MS,and Ali Syed, BDS, MS , CBCT imaging was reported to have twice the odds of detecting a periapical lesion than traditional periapical radiography in endodontic outcome studies. [10] For an obvious lesion in which a clear diagnosis may be made it might not be of concern, but when clinically challenged with a difficult diagnosis and / or decision making, CBCT imaging might provide a greater amount of information needed to establish diagnosis. [10]
6C. Cone beam technology in periodontal assessment
In the clinical case report from 2017 by Suphanantachat , they compared the accuracy of cone beam computed tomography with standard intraoral radiography methods in patients with infra bony defects.
The study included 25 subjects who suffered from periodontitis and at least two infrabony defects. The overall agreement between IOR and CBCT for periodontal diagnosis, prognosis, infrabony defect type and infrabony defect treatment were 79.3%, 69.5%, 44.7% and 64.2%.
IOR underestimated diagnosis, prognosis and the number of infrabony defect walls at 16.4%, 24% and 37.4%. [12]
In conclusions CBCT was superior to IOR for evaluation of infrabony defect morphology and treatment.
Another study from 2017 evaluated assessment of furcation defects using CBCT and comparison with clinical probing.
The study included 22 patients (50 molar teeth) who met the inclusion and exclusion criteria with at least one molar tooth with grade II or III furcation involvement.
After phase I therapy, furcation involvement was measured using both clinical probing and CBCT imaging technique. The measurements obtained during the OFS (open flap surgery) were then compared with those obtained by clinical probing and CBCT. [13]
Furcation gradings between clinical, open surgical measurements and CBCT findings were statistically insignificant .
However, agreement in the furcation gradings between CBCT and open surgical measurements gave a Cohen Kappa value of 0.89 and it was statistically significant.
The results indicated that there was the highest agreement between measurements obtained using CBCT imaging technique and true level of involvement seen during OFS (89%) when compared to clinical and OFS measurements (11%) and clinical and CBCT measurements (3%).
CBCT can be considered as more efficient diagnostic tool to accurately assess osseous defects at furcation sites when compared to clinical probing.
6D. Cone beam tomography in oral surgery and temporomandibular joint assessment.
In the study from 2015 “Efficacy of CBCT for assessment of impacted mandibular third molars “ by Matzen and Wenzel they have investigated the level of accuracy in validation of radiographic findings and comparison of CBCT to standard radiological methods in assessment of IAN and impacted mandibular third molars.
Study was based on Fryback and Thornbury hierarchical classification system for evaluating the diagnostic efficacy of imaging methods, containing of six levels : technical quality of the imaging method, effect on diagnostic accuracy , effect on the dentist’s diagnostic thinking, effect on the dentist’s choice of treatment, effect on patient’s treatment outcome and effect on societal costs. The diagnostic accuracy of CBCT using a reference standard has generally been sparsely examined. and compared to PAN imaging and SCAN .
Study concluded that CBCT was more reliable than PAN imaging for evaluation of number of roots and was found to be superior to SCAN for assessing root flex in the bucco - lingual direction. More over , the decision making process was explored, whether the information from CBCT changes the surgeons diagnostic thinking, that is, treatment planning. It was concluded that CBCT contributed to “optimal” risk assessment and, as a consequence, to more adequate surgical planning. The observers reclassified more subjects to a lower risk for IAN injury after the CBCT images were available, which also resulted in a significant difference in the suggested surgical approach.
Study included in the review found that in 256 operated patients, 2 in the CBCT group and 5 in the PAN imaging group experienced permanent sensory disturbances to the IAN. [14]
In conclusion, review suggests that CBCT does not change patient outcome compared with PAN imaging, but obviously, more RCTs of removal of third molars in various impaction states and operation complexity are needed. [14]
The costs for a CBCT examination varied between approximately €70 and €180 , and the costs for a PAN image varied between €25 and €50, depending on variations in capital costs and number of performed examinations yearly. [14]
In the research by J. Radic “ Do we need CBCTs for sufficient diagnostics? “ 2018, Fourteen residents were recruited to evaluate nine selected cases with different dento - alveolar pathologies. The residents were given for each case an OPG, a CBCT and a printed 3D model.
For each case and imaging modality, the residents were asked several questions relating to diagnosis, and the request for consecutive imaging in order to enable treatment.
Diagnostic accuracy compared OPG to CBCT was equal to OPG 66.3%, CBCT 83.4% for OS residents and equal to OPG 63.7%, CBCT 78.0% for ORTH residents.
In conclusions of the study , overall diagnostic accuracy of OPG and can be improved with CBCT.
CBCT shows promising results in the diagnostics of TMJ disorders , in the article form 2015 by T.A. Larheim “ Temporomandibular joint diagnostics using CBCT “ they have review clinical accuracy fo CBCT in diagnostics of intra-articular disorders , juvenile idiopathic arthritis , juvenile osteoarthritis and general osteoarthritis of TMJ.
The review concluded that the imaging modality of cone beam tomography is superior to conventional radiographic methods, as well as MRI, in the assessment of osseous TMJ abnormalities. In all of the listed disorder , cone beam showed higher accuracy in imaging and increased precision in treatment planning.
6E. Cone beam tomography in orthodontic evaluation.
In the study from year 2018 “ 3 - dimensional cone - beam computed tomography superimposition “ by J.H. Park , they compare the advantages and limitations of cone beam technology to standard 2D radiography. Article presents that the main advantage of CBCT is its higher accuracy in assessment of anatomical landmarks and main limitations are errors occurring while user’s interpretation of the image , software/hardware errors and minor misbalances in data visualisation and and displacement of directions. However, to establish a simple, faster and more effective diagnostics using CBCT, reviewers suggest implementation of more user friendly methods of configurations and protocols proceeding . In conclusions 3D superimposition is superior to the standard two dimensional methods , but further research need to be established due to overall controversy in the literature.
6F. Cone beam tomography in implantation treatment planning.
In the article from 2016 by Dorothea C. Dagassan - Berndt, about implant treatment planing ,they have compared panoramic radiographs to CBCT, in patients requesting single implants with lateral and vertical bone augmentation. 40 patient’s images , panoramic and CBCT, were analysed by 6 specialists in implantology. Cone beam provided more detailed information about the patients anatomy which lead to more options for treatment planing. 3D technology evaluation suggested more invasive treatment methods in comparison to panoramic radiography which underestimated the degrees of invasiveness of surgical procedures. However, in conclusions authors claim, that the most important factor is clinician's diagnostics skills. Broader scale investigation of the topic should be proceeded to conclude if CBCT has more positive impact on the diagnostic and treatment outcome.
Another study from 2014, investigated choice of dental implant size based on panoramic radiography, CBCT generated panoramic x-ray , and CBCT cross - sectional imagining.
Study was performed on 71 patients with total number of 103 dental implant sites.
Report concluded that CBCT cross - sectional technique influences clinician to chose shorter and narrower implants types for both maxillar and mandibular sites , due to 3D images generation and more detailed anatomical landmarks with leads to performing less clinical errors.
Retrospective analysis (Aleksandar Vujanovic-Eskenazi e.al.2015) about evaluation of anterior loop of mental nerve before placement of implant concludes that even with minimal statistically significant differences between PAN and CBCT , due to cone beam accuracy superiority , it should be recommended to perform 3D imaging in the anterior mandible implant loading , to minimise risk of nerve injury and maximise the availability of the space from the prosthetic point of view.
DISCCUSION
This systematic review was design to determine if CBCT can become a golden standard in the everyday work of the odontologist. There are many reviews and articles about cone beam accuracy and superiority in comparison to standard radiographic methods, but none of them seems to answer the question if it can be the main diagnostic tool in every field of dentistry.
Data collected in this literature review illustrates that 3D CBCT has high potential in becoming a golden standard diagnostic method in the near future.
Big range of success and accuracy of diagnostics obligates doctors to use this technology more frequently, from simple to complicated clinical cases.
However, due to ALARA principles about reducing radiation exposure, use of CB can raise questions if it is essential or essentially “ overkill”. Although, due to rapidly advancing imagining technology, improvements in radiation-sensitive organs shielding and effective radiation dosage lessening , the uncertainty about its safety for patients reduces. In article by Sean Carlson - 2011, “ The truth about CBCT radiation “ the author compares effective dosage of cone beam , to every day “background’ radiation exposure. It concludes that one air travel is equal in radiation to one CBCT scan. The publication suggests that more frequent usage of volumetric tomography should be essential due to its simplicity, reduced error risks and time of treatment , as well as being more beneficial for patients , than harmful.
Price for cone beam varies between €70 and €180, which maybe seem financially troubling , due existence of cheaper alternative - PAN images ( €25 and €50 ). However with the technology become more popular and available in broader range of clinics, the price tends to have dropping effect. The questions that raises when thinking about price is, if is it more reasonable to pay more for diagnostic tool and avoid underestimation of problem and occurrence of complications or pay less and be expose for the risks and additional costs for retreatment procedures ?
In recent studies, the efficacy of CBCT has been evaluated for caries diagnosis. Some of them have concluded that the accuracy of cone beam may be similar to that of intraoral digital radiographic images for occlusal and proximal caries detection. Nevertheless, 3D images were found to be superior to intraoral techniques in other studies for secondary caries lesions under both composite and amalgam restorations. Secondary caries under restorations is the most common reason for retreatment and replacement in restorative failures. To prevent severe destruction of hard tissue and also to enhance the prognosis for a successful treatment outcome, it is important to diagnose secondary caries earlier
The success of endodontic treatment depends on the precision of investigation of root and root canal anatomy. Due to the complexity of the canal system and anatomical variations, it is highly critical to identify and provide proper treatment. Due to development of 3D cone beam computed tomography, detailed and precise information are available to gather with high accuracy. The main advantages of this scanning technology are its minimal distortion of the view, 3D visualisation of the subject and accuracy.
Standard radiographs are an integral part of treatment and root canals identification ,but offer limited information - a two-dimensional representations of three-dimensional structures.
CBCT overcomes those limitations by providing three-dimensional images with higher resolution. It shows widely its use in establishment of extra canal in MB2 of maxillary first molars and visualisation of unusual anatomy that can often be missed on routine radiographs.
Intraoral radiography including periapical and bitewing radiographs are also widely used for evaluating alveolar bone destruction pattern and level.
IOR are simple to acquire with low cost and relatively low radiation dose.
Even so, limitation is the two dimensional nature of the images. This often provides insufficient amount of information in cases of multi-rooted teeth, border and floor of maxillary sinus and infrabony defects. The information provided is often inaccurate making it more difficult to establish proper treatment plan.
In orthodontics , cone beam shows promising results in treatment planing , as more accurate alternative for panoramic cephalometry. Despite that, more user friendly protocols need to be established to achieve its peak of functional capability.
Last but not least, successful treatment planning in oral surgery or implantation procedures strongly depends on data collected while analysing anatomical peculiarities and landmarks. 3D imagining affects the clinicians point of view , critical thinking which leads to establish more accurate , safe and less invasive procedures. Use of cone beam, can prevent clinical errors, underestimating or misdiagnosing the patient’s health problem.
The controversy around everyday usage of cone beam is a major factor in its progress of broader establishment within the dental practitioners. Confusion and misunderstanding about effective radiation dosages , price per image and lack of user friendly protocols prevents CB from reaching its full diagnostic potential , and narrows its use only for complicated procedures.
Within the limits of this literature review , collected data suggests, that 3D CBCT raises to the highest standards of diagnostics imaging. Cone beam technology can be used in every field of
surgical procedures and changes clinician thinking in planning of the treatment. It has higher accuracy , collects more information per image and has broader spectrum of problem analysis. Yet, despite the controversies , concerning effective radiation dosage and ALARA principles , continuous development in technology and methods of safety and shielding involving both solid clinical and theoretical based research shows promising results in becoming golden standard diagnostic method in the future.
CONCLUSIONS
Collected data suggests, that 3D CBCT raises to the highest standards of diagnostics imaging. Cone beam technology produces higher radiation exposure for patients in comparison to classic radiological methods, however studies suggests that it should not be a major factor which could prevent from using it in broader scale.
On the other hand , for simple procedures, conventional radiographic methods like panoramic x-ray, apical x- ray or bitewing seem to provide sufficient amount of diagnostic information. Nevertheless, CBCT produces superior results and can decrease the risk of underestimation of the problem.
Finally, a larger scale investigation should be perform to assure the essentiality of the CBCT in everyday practice of a dentist. Although , the answer for the aim’s question is positive, but the major factor it depends on, is the dental practitioner choice and patients will and agreement.
REFERENCES
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ANNEXES
Table 2. Characteristics of studies
Author’s name Year of study Field of
dentistry designStudy Number of patients Number of teeth Accuracy of CBCT/ Conclusions
Elif Y. Keris 2017 cariology/
prosthodontics CR ( in vitro ) 128 CBCT more accurate in detecting caries under restorations Vedpathak. P.R. 2016 cariology/ prosthodontics CR ( in vitro ) 6 CBCT more accurate in detecting caries under FDP
Aminoshriae A. 2018 endodontics CR ( in vitro ) - CBCT more
accurate in detecting periapical lesions Suphanantachat S. 2017 periodontology CR 25 - CBCT superior in detecting infrabony defects Jayachandran C. 2017 periodontology CR 22 50 CBCT more accurate in assessment of infrabony defects. Matzen L.H., Wenzel. A.
2015 oral surgery CR 256 - CBCT affects
diagnostic thinking and treatment planning
Radic J. 2018 oral surgery RA - - Accuracy in
diagnostics using CBCT increased
Larheim T.A. 2015 maxillofacial
surgery RA - - CBCT more accurate in assessment of TMJ pathologies
Park. J.H. 2018 orthodontics RA - - CBCT higher accuracy in orthodontics superimpositio n
Dagssan C.D. 2016 implantology CR 40 - CBCT suggests
less invasive treatment plan in implant placement procedures Correa L.R. 2014 implantology CR 71 103 CBCT influences choice of implant size.
Eskanazi V.A 2015 implantology CR - - CBCT more
accurate in assessing location of the mental nerve
