Anda di halaman 1dari 13

Australian Dental Journal

The official journal of the Australian Dental Association


Australian Dental Journal 2012; 57:(1 Suppl): 82–94

doi: 10.1111/j.1834-7819.2011.01661.x

Application of cone beam computed tomography in oral and


maxillofacial surgery
M Ahmad,* J Jenny,  M Downieà
*Associate Professor and Director, Division of Oral and Maxillofacial Radiology, School of Dentistry, University of Minnesota, Minneapolis,
Minnesota, USA; Director, American Board of Oral and Maxillofacial Radiology.
 Partner, Twin Cities Oral and Maxillofacial Surgery PA, Minneapolis, Minnesota, USA; President, Advanced Head and Neck Imaging LLC,
Minneapolis, Minnesota, USA.
àPartner, Twin Cities Oral and Maxillofacial Surgery PA, Minneapolis, USA; Vice President, Advanced Head and Neck Imaging LLC,
Minneapolis, Minnesota, USA.

ABSTRACT
In the past decade, the utility of cone beam computed tomography (CBCT) images in oral and maxillofacial surgery has seen
continuous increase. However, CBCT images are not always able to replace other imaging modalities. Based on the current
published knowledge, this paper discusses advantages and limitations of CBCT images in the diagnosis and surgical
planning of dentoalveolar procedures, odontogenic cysts, benign and malignant tumours, inflammatory changes,
orthognathic surgery, maxillofacial trauma, sinus disorders, and systemic and osseous conditions that manifest in the
maxillofacial area. This paper also suggests alternative imaging modalities when CBCT images are not adequate for surgical
planning.
Keywords: Dental radiography, oral surgery.
Abbreviations and acronyms: BRONJ = bisphosphonate-related osteonecrosis of the jaws; CBCT = cone beam computed tomography;
MDCT = multi-detector CTs; MRI = magnetic resonance imaging; OMS = oral and maxillofacial surgery.

As the CBCT slices can be reformatted and viewed in


INTRODUCTION
multiple possible orientations (multiplanar views),
The introduction of cone beam computed tomography anatomic structures are not superimposed (Fig. 1).1
(CBCT) has dramatically changed how an oral and Within the last decade, the technology and design of
maxillofacial surgeon conducts his or her practice. This CBCT scanning machines has made the placement of
technology has improved the efficiency of oral and the machines both physically and financially possible.
maxillofacial surgeons in private offices, where access Greater access to interoffice scanners allows for a
to cross-sectional imaging has now become quicker and greater ease of patient acceptance and use for the
easier than in a hospital-based practice. Prior to the treating surgeon.
introduction of CBCT, panoramic radiography was the Prior to the introduction of CBCT, multiplanar
most common imaging tool in private oral and views were obtained primarily with multi-detector CTs
maxillofacial surgery (OMS) offices. Only limited cases (MDCT) and magnetic resonance imaging (MRI). Phys-
were evaluated with cross-sectional imaging. While oral ical dimensions and cost of MDCT and MRI equipment
and maxillofacial surgeons have successfully practised are prohibitive for installation in a typical OMS office.
using panoramic radiography, the limitations of this Smaller physical dimension, lower cost and easier
imaging technique include variable magnification, dis- operation have led to rapid acceptance of CBCT units.
tortion, superimposition of structures, and suboptimal There are many instances where an oral and maxillofa-
imaging of structures not located in the focal trough. cial surgeon may reliably use a CBCT scan where an
CBCT has overcome these limitations. Depending on MDCT may otherwise have been chosen to provide
the field of view, CBCT scans show a large area of the diagnostic information. However, the need of MDCT
facial skeleton beyond the limits of a panoramic and MRI examinations in oral surgery is not obsolete,
radiograph or a small area of focused clinical interest. even though the quality of CBCT images may be better
82 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

(a) alveolar canal and its close contact to the third molar
root structures are risk factors in dentoalveolar surgery.
Therefore, image analysis principles were developed for
panoramic or periapical radiographs to identify the
canal location.3 However, the inferior alveolar canal
may follow a tortuous path, and may not be reliably
interpreted on a 2-D image. Multiplanar views from a
CBCT are useful not only in tracing the canal, but also
in assessing a bifurcated or trifurcated canal (Fig. 2).4
In addition, knowledge of the location of the canal
(b) (c) allows the surgeon to develop a safer surgical plan
related to the access to the tooth and root elevation.
Ankylosis of impacted teeth adds another layer of
complication in dentoalveolar surgery. Plain films are
not reliable in revealing ankylosis of teeth.5 Compared
to panoramic radiography, CBCT images allow better
risk assessment of third molar removal.6 Panoramic or
periapical radiographs are often inadequate to locate
impacted maxillary canines and to identify their
relationship to the roots of the lateral incisors. Surgical
Fig 1. (a) A panoramic radiograph revealed a suspicious radiolucent
exposure of the canine crowns for orthodontic bracket
bony defect (arrow) in the region of the missing right maxillary canine. placement may require multiple periapical radiographs
The first premolar root is displaced distally, and the lateral incisor is obtained at differing horizontal or vertical angles.
displaced mesially. (b) and (c) Data acquired using an iCAT CBCT
machine. Images are reformatted in iCATVision software and
Application of image shift principles is complicated
OnDemand 3D, a third-party software. The labial cortical plate is well and time consuming. A surgeon can eliminate the
defined and smoothly corticated in the edentulous region of the canine. complication of guess-work when CBCT scans are
The 3-D reconstruction shows this ‘bony defect’ being a prominent
canine fossa.
available (Fig. 3). The use of 3-D reconstructions also
allow for a more complete visual picture for the treating
than MDCT scans.2 A study that evaluated the image orthodontist to provide proper vectors of tooth move-
quality of bone structures acquired by five different ment.
CBCT machines and one MDCT machine showed that
the image quality of one CBCT machine was superior to
Use of CBCT for benign lesions and cysts
that from the tested MDCT machine while images from
other CBCT units were comparable to the test MDCT In evaluating cysts or benign tumours, intraoral or
images.2 However, soft tissues are better displayed on panoramic radiographs show only the two dimensions of
MRI and soft-tissue window CTs. Currently, neither the lesion. Observation of the third dimension, i.e.
MDCT nor CBCT can replace the MRI where soft tissue bucco-lingual extension of a lesion, requires additional
diagnosis is the primary aim. These situations include radiographs obtained at 90 degrees from the original
analysis of soft tissue tumours, extension of intraosseous view. In contrast, all three dimensions are recorded by
tumours into surrounding soft tissue and position of the the multiplanar (axial, coronal and sagittal planes)
disc in temporomandibular joints. imaging of CBCT (Fig. 4). Such multiplanar views
Major uses of CBCT examination in oral surgery provide important information on the presence and
practice include surgical extraction of third molars and extent of bone resorption, sclerosis of neighbouring
impacted teeth, tracing of the inferior alveolar canals, bone, cortical expansion and internal or external calci-
implant planning, evaluation of cysts and tumours, fications, and proximity to other vital anatomy (Fig. 5).7
fracture diagnosis, orthognathic surgical planning and Multiplanar sections are preferred when examining cysts
follow-up, inflammatory conditions of the jaws and the or tumours deep in the tissues.8,9 If the lesion borders can
sinuses, evaluation of the temporomandibular joints, be clearly seen, then multiple extraoral plain film
and as an aid in diagnosing unexplained symptoms of radiographs, oriented at 90 degrees to each other, can
pain. The following subsections provide utility of provide adequate information of the size of a lesion.
CBCT in different surgical situations. Information on the spatial relationship of the lesion with
other anatomic landmarks on such images is limited, and
often difficult to interpret. Because of superimposition of
Evaluation of impacted teeth
large tissue volume, extraoral plain film radiographs
Dentoalveolar surgery for impacted teeth is a common often cannot provide reliable information on the internal
procedure in an OMS office. Location of the inferior structure of a lesion.
ª 2012 Australian Dental Association 83
M Ahmad et al.

(a) (b) (c)

Fig 2. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (a) and (b) Coronal sections of the left
mandibular third molar region from the same patient. (a) The third molar root has branches of inferior alveolar canal on the buccal and lingual
aspects. (b) Bifurcated inferior alveolar canal is visible distal to the left mandibular third molar region. (c) A thin slice in the left mandibular
edentulous third molar area shows a roughly vertical accessory branch of the inferior alveolar canal.

(a)

(b) (c) (d)

Fig 3. (a) Multiple impacted teeth, 12-year-old male. The panoramic radiograph was acquired on an orthodontic patient to evaluate delayed
eruption of the right maxillary canine, premolars and second molar. (b), (c) and (d) Data acquired using an iCAT CBCT machine. Images are
reformatted in iCATVision software and OnDemand 3D, a third-party software. (b) A maximum intensity projection view shows the relationships of
the impacted teeth. (c) and (d) Manipulation of the 3-D images and cine mode (not shown) help in locating the impacted teeth and their relationship
to each other.

(a) (b) (c) (d)

Fig 4. Radicular cyst, 60-year-old male. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (a)
Reconstructed panoramic view shows well-defined lucent lesion in the left maxillary canine premolar area. The wall of the sinus is displaced. (b) Axial
section shows destruction of the palatal bone. (c) Coronal section shows disruption of the floor of the nasal cavity, hard palate, and the buccal
cortical plate of the alveolar bone. (d) Sagittal section shows disruption of the floor of the nasal cavity and expansion of the palatal cortical plate.

Newer CBCT units allow slice thickness to be as low surgeons may depend on panoramic radiography if the
as 0.1 mm. These thin slices allow better visualization margins of cystic or benign lesions are well defined.10 If
of the bony margins of a lesion. Oral and maxillofacial the margins are ill-defined, CBCT is a better option for
84 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

(a) (b) (c)

Fig 5. Ameloblastoma, 39-year-old female. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software.
(a) Reconstructed panoramic view shows multilocular lesion in the mandibular right molar area. The inferior border of the mandible is thin and
slightly expanded. (b) Axial maximum intensity projection view shows buccal and lingual expansion. The lingual cortical plate is thin and partially
resorbed. (c) Coronal section through the third molar area. Compared to the normal left side the right side shows expansion in the bucco-lingual
aspect and lower border of the mandible.

(a) (b)

(c) (d)

Fig 6. Recurrent ameloblastoma, 59-year-old female. (a) Periapical radiograph acquired in 1997. The well-defined corticated radiolucent lesion
superimposed over the second molar root was missed by a general dentist. (b) Panoramic radiograph acquired in April 2010 shows multiple
radiolucent lesions in the mandibular third molar area. The lesion superimposed over the second molar root appears to be larger than the lesion in
1997. The patient reports that the third molar was extracted about 30 years ago and a ‘cyst’ was removed. (c) and (d) Data acquired using an iCAT
CBCT machine in April 2010. Images are reformatted in iCATVision software. The radiolucent defects are separated by normally appearing bone
(arrow).

diagnosis.11 Apart from presurgical evaluation of


Use of CBCT for malignant lesions
aggressive benign cysts or tumours, CBCT is also
helpful in post-surgical follow-up of the margins of The limitation of plain films in depicting the margins of
lesions that may have a high recurrence rate (Fig. 6). A a benign lesion is also encountered in diagnosing
surgeon may find CBCT scans acquired in their own malignant lesions. A lesion that may have a ‘benign’
OMS office more convenient and diagnostically suffi- appearance on a panoramic radiograph could reveal
cient compared to MDCT scans (Fig. 7). ominous features in thin slices of CBCT scan (Fig. 8).
For surgical planning, a lesion may need to be Compared to smooth margins of cysts and benign
measured from different angles. For osseous compo- tumours, the margins of malignant tumours are irreg-
nents, when compared to the gold standard dry ular. CT images can identify such irregular margins and
skull, the measurements on CBCT images are provide information in the early stages of a malignant
acceptably accurate with less than 1% error.12,13 In lesion (Fig. 9). The advantage of CBCT over MDCT
comparison, panoramic radiographs are not reliable lies in the lower radiation dose and low cost.15
for size measurement due to variable magnification Whenever a malignancy is suspected to involve osseous
error.14 components, cross-sectional imaging with CT or CBCT
ª 2012 Australian Dental Association 85
M Ahmad et al.

(a) (b) (c)

(d) (e) (f)

Fig 7. Recurrent keratocystic odontogenic tumour, 18-year-old female. (a), (b) and (c) were acquired by a MDCT machine in 2007. Images are
reformatted using OnDemand 3D, a third-party software. The reformatted panoramic view shows keratocystic odontogenic tumours in the
right maxillary sinus area and left mandibular second premolar first molar area. (b) and (c) The keratocystic odontogenic tumour occupies almost the
whole right maxillary sinus. The third molar is displaced superiorly and anteriorly. The lateral wall of the maxillary sinus is displaced and partially
resorbed. (d), (e) and (f) Follow-up examination was acquired in 2009 using an iCAT CBCT machine. Images are reformatted in iCATVision
software. (d) On the reformatted panoramic view, the right maxillary sinus area is sclerosed. The keratocystic odontogenic tumour in the left
mandible is now healed. (e) and (f) Sagittal and coronal views show recurrence of the maxillary keratocystic odontogenic tumour. The margins of the
lesion are well-defined, smooth and corticated.

(a) (b) (c)

(d) (e)

Fig 8. Squamous cell carcinoma, 72-year-old male. (a), (b) and (c) were acquired using an iCAT CBCT machine. Images are reformatted in
iCATVision software. A periapical radiograph (not shown) of the mandibular third molar area suggested a dentigerous cyst associated with the third
molar. Thin slice (b) showed loss of lamina dura of the second molar. (c) Coronal views show resorption of the lingual cortical plate. A dentigerous
cyst is likely to expand the cortex. (d) The panoramic radiograph was acquired immediately after extraction of the third molar and before the
histopathologic examination. (e) Follow-up examinations after surgical resection and grafting are being done with panoramic radiographs.

must be obtained (Fig. 10). CBCT images are as reliable


Use of CBCT for inflammatory changes in the bone
as MDCT images in predicting bone invasion by
malignant lesions.16 CBCT images are not useful in As mentioned in the previous paragraph, irregular
analysing soft tissue tumours, rather MRI or soft tissue margins are a common radiographic feature of malig-
window MDCT is a better diagnostic tool. Multiple nancy. Interestingly, osteomyelitis has similar irregular
examinations using CBCT, MDCT, MRI or nuclear margins. However, a malignant lesion is less likely to
medicine may be needed for a complete diagnostic develop a new layer of periosteal bone, while chronic
work-up of a patient with a malignant lesion. infection frequently results in such layering. Periosteal
86 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

reaction and cortical destruction, as viewed on multi- Features of osteomyelitis are also seen in bisphosph-
planar images, can be useful in differentiating these onate related osteonecrosis of the jaws (BRONJ).
radiographically similar lesions of widely different Although BRONJ is a debilitating condition, fortu-
prognosis (Fig. 11).17,18 If the infection is acute, neither nately the incidence of this disease is low. In 2004 and
plain film radiography nor CBCT scan is useful, as early 2005, a survey of Australian oral and maxillofacial
infection does not cause enough bony change to be surgeons identified 158 cases of BRONJ.19 Since that
radiographically detectable. If an aggressive infection time, the prescriptions of bisphosphonate have in-
persists for two weeks or more, the primary finding on a creased. In evaluating BRONJ, CBCT images are better
radiograph is a lytic lesion with irregular margins. If the than panoramic radiography.20 Currently, all these
infection is chronic or moderate to low grade, the bone imaging modalities have limited values in detecting
appears of mixed density. The margin of a chronic early stages of the disease.21,22 BRONJ may also be
infection is often sclerotic and can be adequately associated with failing dental implants. In South
viewed on plain film radiographs. To identify periosteal Australia, seven BRONJ-related implant failures were
bony reactions, oral and maxillofacial surgeons tradi- reported in a population of 16 000 patients.23 In
tionally used occlusal radiographs. However, wrong implant cases, MDCT is likely to produce image
exposure factors or angulation can limit the utility of an artefacts arising from metal implants. CBCT can be
occlusal radiograph to demonstrate a thin periosteal used to evaluate the status of alveolar bone adjacent to
bony layer. With CBCT images, where multiplanar the implants and also as a follow-up examination
slices are easy to adjust, thin layers of periosteal bones (Fig. 11C and 11D).
are better viewed compared to occlusal radiographs.
In addition, small bony sequestra associated with
Orthognathic surgical planning and follow-up studies
osteomyelitis are better identified with cross-sectional
imaging. For orthognathic surgery, DICOM data from CBCT
can be used to fabricate physical stereolithographic
(a) (b) models or to generate virtual 3-D models.24–26 Such
3-D reconstructions are most useful for morphological
analysis and spatial relationship of the neighbouring
structures as well as for growth and developmental
anomalies, gross tumour development or fracture
displacement.8,27 These 3-D surface models generated
from CBCT data may be slightly inferior to that from
MDCT, but are usually of acceptable quality.28 The
3-D reconstructions are extremely useful in the diag-
nosing and treatment planning of facial asymmetry
cases. Airway measurement techniques are improving
with newer software options.29,30 These data are being
Fig 9. Metastatic cancer, 81-year-old male. Data acquired using an
iCAT CBCT machine. Images are reformatted in iCATVision
used for surgical orthodontic cases as well as for sleep
software. (a) Reconstructed panoramic view shows irregular lesions apnoea patients.31 Follow-up CBCT imaging is useful
in the mandibular right second molar area and the vertical ramus. in evaluating the success of orthognathic surgery
The second molar was extracted a few months before this scan.
(b) Coronal view of the left ramus shows multiple radiolucent areas
(Fig. 12), as well as to measure the displacement of
and disruption of the buccal and lingual cortical plates. the surgical segments in all three orientations.25

(a) (b)

Fig 10. Chondrosarcoma of the nasal septum, 59-year-old female. Data acquired using an iCAT CBCT machine. Images are reformatted in
iCATVision software. The scan was requested based on a finding on a panoramic radiograph. (a) Axial view shows a roughly oval soft tissue density
mass present in the anterior part of the nasal septum. (b) The sagittal views show the soft tissue density mass is at the floor of the nasal cavity. The
floor is disrupted. Presence of thin calcifications in the mass suggest high grade lesion. Low grade lesions are usually uniformly dense.

ª 2012 Australian Dental Association 87


M Ahmad et al.

(a) (b)

(c) (d)

Fig 11. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (a) and (b) Chronic osteomyelitis,
71-year-old female. (a) Mixed density appearance in the left mandibular posterior region. The inferior border of the mandible is partially disrupted.
(b) On the coronal view at the level of the first molar area, the arrow points to periosteal new bone formation. (c) and (d) Bisphosphonate-related
osteonecrosis of the jaw, 59-year-old female. (c) The scan was acquired to evaluate failing implants in the right mandible. Compared to the normal
left side, the right molar area has increased sclerosis. (d) Follow-up examination three months post-implant removal, the lingual cortical plate is
disintegrating. Periosteal new layer of bone is visible in the lingual aspect of the third molar area.

industrial accidents involving jaws and other parts of


Fracture of dentomaxillofacial structures
the body.
The diagnosis of a simple dental or jaw fracture can be
achieved with periapical or panoramic radiographs.
Use of CBCT for diseases of paranasal sinuses
Initial assessment of a complex jaw fracture may also
be performed with plain films. However, vertical root In addition to dental offices, ENT practitioners are also
fracture or multiple jaw fractures with bone displace- using CBCT units as an efficient in-house examination
ment may be better evaluated with CBCT images. tool. Likewise for oral and maxillofacial surgeons,
Compared to periapical radiographs, CBCT images are identifying the condition of the maxillary sinuses is
significantly better for diagnosing root fractures.32,33 important for implant planning and to rule out sinus
For complex jaw fractures, CBCT may be a valid disease as a cause for orofacial pain (Fig. 14). Sinusitis,
alternative imaging tool to MDCT, considering radia- a common inflammatory disease involving the maxil-
tion dose and image quality.34 Non-displaced fractures lofacial skeleton, is often of odontogenic origin.35,36 In
of the mandibular condyle can be very difficult to some cases with sinusitis, endodontic therapy of the
diagnose with conventional radiographs. Multiplanar offending tooth may fail, requiring a surgical interven-
views of CBCT scans allow much better assessment of tion.37 CBCT not only provides diagnostic information
interarticular fractures of the condylar head. Currently, of the status of extension of periapical lesions into the
most dental CBCT units require the patient to be in an maxillary sinuses,38 but also provides reliable
upright sitting or standing position during image information on the septa of the sinus and presence of
acquisition. Therefore, a CBCT unit in its current exostoses, useful presurgical information when plan-
configuration may not be appropriate where trauma to ning sinus floor augmentation in preparation for
the cervical vertebra is also suspected and the neck is implant placement.39
stabilized. In addition, involvement of cranium and Waters’ sinus view, a traditional sinus examination,
leakage of cerebro-spinal fluid cannot be studied with is now considered inadequate in detecting maxillary
CBCT. The role of CBCT in fracture diagnosis, sinus opacification and ‘very poor’ in detecting masses
therefore, appears to be limited to fracture of teeth in the ethmoid, frontal and sphenoid sinuses.40,41
and jaw fractures from fall, sports-related injury CBCT images are helpful in identifying mucous reten-
(Fig. 13) or minor assault. MDCT with or without tion phenomena, antral polyps, sinonasal polyposis and
MRI is a better imaging choice in automobile or malignant tumours of the sinuses. In addition, an oral
88 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

Fig 12. Follow-up of orthognathic surgery. (a)–(f) are from the same patient, 54-year-old female. Panoramic radiograph acquired in May 2005, three
months after orthognathic surgery. Both the condylar heads are partially visible. (b)–(f) Data acquired in October 2009 using an iCAT CBCT
machine. Images are reformatted in iCATVision software and InVivo, a third-party software. (b) Axial view shows absence of lateral and medial
pterygoid plates on the left side (arrows). (c) 3-D reconstruction shows satisfactory anterior occlusion, although the patient reports that her lower jaw
deviates to the right side during opening. (d) and (e) The left condylar head and neck is completely resorbed, possibly because of lack of adequate
pterygoid muscle strength due to missing pterygoid plates. (f) The right side of the condyle (not completely shown) is present and has a flattened
superior margin. (g)–(i) Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. Bilateral sagittal split
osteotomy and grafting. (h) Incomplete integration of the graft materials on the buccal cortical plates. (i) Disrupted inferior alveolar canal margin
(arrow).

(a) (b)

Fig 13. Multiple jaw fracture, 22-year-old female, professional basketball player. Data acquired using an iCAT CBCT machine. Images are
reformatted in iCATVision software. The patient fell on the basketball court and fractured the left condyle and the symphysis area. (a) Maximum
intensity projection shows bone plates and the symphysis region and the left condylar and neck area. (b) A thin layer of periosteal new bone
formation (arrow) on the lingual aspect of the left ramus is consistent with remodelling.

ª 2012 Australian Dental Association 89


M Ahmad et al.

(a) (b)

(c) (d) (e)

Fig 14. Ewing’s sarcoma, 8-year-old male. (a) Panoramic radiograph was taken to evaluate right-sided jaw pain. The crown of maxillary right
second molar is rotated posteriorly and superiorly. This rotation was significant compared to a previous panoramic radiograph (not shown) acquired
about 2 weeks prior to this radiograph. (b)–(e). Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (b)
Reformatted panoramic view shows soft tissue density mass occupying the posterior part of the maxillary sinus and displacement of the wall of the
sinus. (c) Axial view showed bowing (arrow) of the posterior wall of the right maxillary sinus. (d) Thin slice through the molar area shows disruption
of the pterygopalatine fossa and displacement of the posterior wall. The posterior part of the orbital floor is partially resorbed. (e) The right
pterygoid canal is obliterated (compare with the unaffected left side, arrow).

(a) (b) (c)

Fig 15. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (a) and (b) are from the same patient. (a)
Oro-antral fistula (arrow). (b) Displaced root fragment into the sinus. Note the opacity of both the maxillary sinuses. (c) Oro-antral fistula (arrow)
and polypoid tissues in the left maxillary sinus, nasal cavity and ethmoid air cells.

and maxillofacial surgeon should consider a CBCT scan


Craniofacial disorders
if there is a suspicion of oro-antral fistula formation or
if an implant is displaced into the sinus (Fig. 15). Frequently, patients with developmental disturbances
A limitation of CBCT is its poor resolution of soft require surgical treatment. CBCT images are invaluable
tissues.42 Sinus masses can be composed of different in patient education, treatment planning and as a
types of soft tissues with or without fluid accumulation. follow-up study to evaluate growth, development and
In addition, the fluid may be thin watery secretion function. For a cleft palate patient, use of a panoramic
blood or a mix with pus. On a CBCT scan, a mass in radiograph is limited to identifying an alveolar cleft
the sinus usually has a uniform density. Therefore, only. Cross-sectional imaging, such as with CBCT,
differentiation of the density into a fluid or soft tissue assists in the assessment of the width of the cleft, tooth
mass is often not reliable. CBCT data can be relied on proximity to the cleft, deviation of the nasal septum
for the size and margin of the sinus mass, status of the and its degree of fusion to the palate, as well as the
sinus wall, and blockage of the ostium. Some software location of supernumerary teeth and the visualization
allows measurement of the air space, which can be of the entire osseous defect. Thorough evaluation of the
accurate.43,44 Fungal sinusitis often accumulates calci- maxillofacial structures with cleft or other develop-
fied materials. On a CBCT scan, these calcified mental defects and syndromes can be achieved with
materials can be easily differentiated from the soft cross-sectional imaging and 3-D reconstruction
tissue component of the sinusitis. (Fig. 16).
90 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

(a) (b) (c)

(d) (e) (f)

Fig 16. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software and OnDemand 3D, a third-party software.
(a)–(c) are from the same patient. Unilateral cleft palate and Class III jaw relationship. The coronal slice shows deviation of the nasal septum. (d)–(e)
are from the same patient. Treacher-Collins syndrome. Note prominent antegonial notch, steep mandibular angle, partially missing zygomatic arch,
and incompletely developed external ear.

(a) (b)

(c) (d) (e)

Fig 17. (a) and (b) are from the same patient. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software and
OnDemand 3D, a third-party software. Maxillectomy of the right side and presence of rib graft. Note absence of metal artefacts arising from bone
plates. (c)–(d) are from the same patient. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. The patient
complained of bilateral facial pain, localized to the temporomandibular joints. A CBCT scan shows presence of twisted metal wires in the soft tissues
bilaterally. The temporomandibular joints were unremarkable. The patient does not recall any surgical procedure in this area.

restorations. Extensive bridgework or metal restora-


Use of CBCT in detecting foreign bodies in the
tions can make a MDCT scan virtually non-diagnostic.
maxillofacial complex
Such artefacts from metal objects are lower on CBCT
One of the limitations of using MDCT scans in the images (Fig. 17A and 17B).45,46 Therefore, CBCT is a
maxillofacial area is artefacts arising from metal better imaging modality to assess metal objects in the
ª 2012 Australian Dental Association 91
M Ahmad et al.

(a) (b) (c)

Fig 18. Data acquired using an iCAT CBCT machine. Images are reformatted in iCATVision software. (a) and (b) are from the same patient.
Sialolith (arrow) of the submandibular gland. (c) Ossified stylohyoid ligament bilaterally (arrow). Note pseudo-articulation on the right side.

face, such as fragments embedded from a gunshot,45,47 CBCT is judiciously used based on expected diagnostic
following automobile or industrial accidents and for gain, cost to the patient and the radiation dose.
localizing retained broken dental needles or surgical
wires (Fig. 17C, 17D and 17E).
REFERENCES
Use of CBCT scans in soft tissue calcifications 1. Angelopoulos C, Thomas SL, Hechler S, Parissis N, Hlavacek M.
Comparison between digital panoramic radiography and cone-
Although CBCT images have low contrast (soft tissue) beam computed tomography for the identification of the man-
dibular canal as part of presurgical dental implant assessment.
resolution, they can be better than MDCT in depicting J Oral Maxillofac Surg 2008;66:2130–2135.
soft tissue calcifications, such as carotid atherosclero- 2. Liang X, Jacobs R, Hassan B, et al. A comparative evaluation of
sis.42 Other calcifications, such as tonsilloliths and cone beam computed tomography (CBCT) and multi-slice CT
sialoliths (Fig. 18A and 18B), are adequately viewed on (MSCT) Part I. On subjective image quality. Eur J Radiol
2010;75:265–269.
CBCT images.48 Ossification of the stylohyoid ligament
3. Rood JP, Shehab BA. The radiological prediction of inferior
can impinge the cranial nerves (classic Eagle syndrome) alveolar nerve injury during third molar surgery. Br J Oral
or the carotid artery (carotid artery syndrome). Surgical Maxillofac Surg 1990;28:20–25.
correction of the ossified ligaments can provide relief of 4. Mizbah K, Gerlach N, Maal TJ, Berge SJ, Meijer GJ. The clinical
the symptoms.49 Although an ossified stylohyoid liga- relevance of bifid and trifid mandibular canals. Oral Maxillofac
Surg 2011 Jun 23. [Epub ahead of print.]
ment can easily be diagnosed on a panoramic radio-
5. Raghoebar GM, Boering G, Vissink A. Clinical, radiographic and
graph, the relationship of the ligament to other histological characteristics of secondary retention of permanent
structures is better evaluated by 3-D reconstruction of molars. J Dent 1991;19:164–170.
CBCT (Fig. 18C). 6. Ghaeminia H, Meijer GJ, Soehardi A, et al. The use of cone beam
CT for the removal of wisdom teeth changes the surgical
approach compared with panoramic radiography: a pilot study.
CONCLUSIONS Int J Oral Maxillofac Surg 2011;40:834–839.
7. Kaneda T, Minami M, Kurabayashi T. Benign odontogenic
In the last decade, CBCT has become an important tumours of the mandible and maxilla. Neuroimaging Clin N Am
diagnostic tool for oral and maxillofacial surgeons. The 2003;13:495–507.
benefit of this imaging modality can be better utilized 8. Yuan XP, Xie BK, Lin XF, Liang BL, Zhang F, Li JT. Value of
by realizing its capacities and limitations. As the multi-slice spiral CT with three-dimensional reconstruction in the
diagnosis of neoplastic lesions in the jawbones. Nan Fang Yi Ke
technology now stands, with respect to evaluating Da Xue Xue Bao 2008;28:1700–1702, 1706.
maxillofacial disease, CBCT is mostly a tool for 9. Hashimoto K, Sawada K, Honda K, Araki M, Iwai K, Shinoda K.
diagnosing diseases of the osseous structures. Currently, Diagnostic efficacy of three-dimensional images by helical CT
it is not useful for the study of lesions limited to soft for lesions in the maxillofacial region. J Oral Sci 2000;42:211–
219.
tissues. Practitioners should exercise caution to avoid
10. Chuenchompoonut V, Ida M, Honda E, Kurabayashi T, Sasaki T.
over-interpretation of the findings on a CBCT scan. A Accuracy of panoramic radiography in assessing the dimensions
combination of clinical information, signs, symptoms, of radiolucent jaw lesions with distinct or indistinct borders.
and radiographic findings should be considered to Dentomaxillofac Radiol 2003;32:80–86.
determine the need for surgery or follow-up examina- 11. Araki M, Kameoka S, Matsumoto N, Komiyama K. Usefulness of
cone beam computed tomography for odontogenic myxoma.
tions. On many occasions, follow-up examination can Dentomaxillofac Radiol 2007;36:423–427.
simply be a clinical examination or a single periapical 12. Ludlow JB, Laster WS, See M, Bailey LJ, Hershey HG. Accuracy
radiograph. The practice of oral and maxillofacial of measurements of mandibular anatomy in cone beam computed
surgeons has become more efficient and successful with tomography images. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;103:534–542.
CBCT, and will continue to benefit OMS offices if
92 ª 2012 Australian Dental Association
CBCT in oral and maxillofacial surgery

13. Stratemann SA, Huang JC, Maki K, Miller AJ, Hatcher DC. 30. Hong JS, Park YH, Kim YJ, Hong SM, Oh KM. Three-dimen-
Comparison of cone beam computed tomography imaging sional changes in pharyngeal airway in skeletal Class III patients
with physical measures. Dentomaxillofac Radiol 2008;37:80– undergoing orthognathic surgery. J Oral Maxillofac Surg
93. 2011;69:e401–e408.
14. Batenburg RH, Stellingsma K, Raghoebar GM, Vissink A. Bone 31. Abramson Z, Susarla SM, Lawler M, Bouchard C, Troulis M,
height measurements on panoramic radiographs: the effect of Kaban LB. Three-dimensional computed tomographic airway
shape and position of edentulous mandibles. Oral Surg Oral Med analysis of patients with obstructive sleep apnea treated by
Oral Pathol Oral Radiol Endod 1997;84:430–435. maxillomandibular advancement. J Oral Maxillofac Surg
15. Closmann JJ, Schmidt BL. The use of cone beam computed 2011;69:677–686.
tomography as an aid in evaluating and treatment planning 32. Varshosaz M, Tavakoli MA, Mostafavi M, Baghban AA. Com-
for mandibular cancer. J Oral Maxillofac Surg 2007;65:766– parison of conventional radiography with cone beam computed
771. tomography for detection of vertical root fractures: an in vitro
16. Dreiseidler T, Alarabi N, Ritter L, et al. A comparison of multi- study. J Oral Sci 2010;52:593–597.
slice computerized tomography, cone-beam computerized 33. Wang P, Yan X, Lui D, Zhang W, Zhang Y, Ma X. Detection of
tomography, and single photon emission computerized tomog- dental root fractures by using cone-beam computed tomography.
raphy for the assessment of bone invasion by oral malignancies. Dentomaxillofac Radiol 2011;40:290–298.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 34. Shintaku WH, Venturin JS, Azevedo B, Noujeim M. Applications
2011;112:367–374. of cone-beam computed tomography in fractures of the maxil-
17. Ida M, Tetsumura A, Kurabayashi T, Sasaki T. Periosteal new lofacial complex. Dent Traumatol 2009;25:358–366.
bone formation in the jaws. A computed tomographic study. 35. Bomeli SR, Branstetter BF, Ferguson BJ. Frequency of a dental
Dentomaxillofac Radiol 1997;26:169–176. source for acute maxillary sinusitis. Laryngoscope 2009;119:580–
18. Schulze D, Blessmann M, Pohlenz P, Wagner KW, Heiland M. 584.
Diagnostic criteria for the detection of mandibular osteomyelitis 36. Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck
using cone-beam computed tomography. Dentomaxillofac Radiol Surg 2006;135:349–355.
2006;35:232–235.
37. Selden HS. The endo-antral syndrome: an endodontic complica-
19. Mavrokokki T, Cheng A, Stein B, Goss A. Nature and frequency tion. J Am Dent Assoc 1989;119:397–398, 401-392.
of bisphosphonate-associated osteonecrosis of the jaws in Aus-
tralia. J Oral Maxillofac Surg 2007;65:415–423. 38. Maillet M, Bowles WR, McClanahan SL, John MT, Ahmad M.
Cone-beam computed tomography evaluation of maxillary
20. Treister NS, Friedland B, Woo SB. Use of cone-beam computer- sinusitis. J Endod 2011;37:753–757.
ized tomography for evaluation of bisphosphonate-associated
osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral 39. Naitoh M, Suenaga Y, Kondo S, Gotoh K, Ariji E. Assessment of
Radiol Endod 2010;109:753–764. maxillary sinus septa using cone-beam computed tomography:
etiological consideration. Clin Implant Dent Relat Res 2009;
21. Bianchi SD, Scoletta M, Cassione FB, Migliaretti G, Mozzati 11(Suppl 1):e52–e58.
M. Computerized tomographic findings in bisphosphonate-
associated osteonecrosis of the jaw in patients with cancer. 40. Konen E, Faibel M, Kleinbaum Y, et al. The value of the occip-
Oral Surg Oral Med Oral Pathol Oral Radiol Endod itomental (Waters’) view in diagnosis of sinusitis: a comparative
2007;104:249–258. study with computed tomography. Clin Radiol 2000;55:856–
860.
22. Stockmann P, Hinkmann FM, Lell MM, et al. Panoramic radio-
graph, computed tomography or magnetic resonance imaging. 41. Aalokken TM, Hagtvedt T, Dalen I, Kolbenstvedt A. Conven-
Which imaging technique should be preferred in bisphosphonate- tional sinus radiography compared with CT in the diagnosis of
associated osteonecrosis of the jaw? A prospective clinical study. acute sinusitis. Dentomaxillofac Radiol 2003;32:60–62.
Clin Oral Investig 2010;14:311–317. 42. Heiland M, Pohlenz P, Blessmann M, et al. Cervical soft tissue
23. Goss A, Bartold PM, Sambrook P, Hawker P. The nature and imaging using a mobile CBCT scanner with a flat panel detector
frequency of bisphosphonate-associated osteonecrosis of the jaws in comparison with corresponding CT and MRI data sets. Oral
in dental implant patients: a South Australian case series. J Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:814–
Maxillofac Surg 2010;68:337–343. 820.
24. O’Neil M, Khambay B, Moos KF, Barbenel J, Walker F, Ayoub 43. Osorio F, Perilla M, Doyle DJ, Palomo JM. Cone beam computed
A. Validation of a new method for building a three-dimensional tomography: an innovative tool for airway assessment. Anesth
physical model of the skull and dentition. Br J Oral Maxillofac Analg 2008;106:1803–807.
Surg 2012;50:49–54. 44. Yamashina A, Tanimoto K, Sutthiprapaporn P, Hayakawa Y.
25. Cevidanes LH, Bailey LJ, Tucker SF, et al. Three-dimensional The reliability of computed tomography (CT) values and
cone-beam computed tomography for assessment of mandibular dimensional measurements of the oropharyngeal region using
changes after orthognathic surgery. Am J Orthod Dentofacial cone beam CT: comparison with multidetector CT. Dentomax-
Orthop 2007;131:44–50. illofac Radiol 2008;37:245–251.
26. Swennen GR, Mollemans W, Schutyser F. Three-dimensional 45. Stuehmer C, Essig H, Bormann KH, Majdani O, Gellrich NC,
treatment planning of orthognathic surgery in the era of virtual Rucker M. Cone beam CT imaging of airgun injuries to the
imaging. J Oral Maxillofac Surg 2009;67:2080–2092. craniomaxillofacial region. Int J Oral Maxillofac Surg 2008;37:
903–906.
27. Cavalcanti Mde G, Antunes JL. 3D-CT imaging processing for
qualitative and quantitative analysis of maxillofacial cysts and 46. Holberg C, Steinhauser S, Geis P, Rudzki-Janson I. Cone-beam
tumours. Pesqui Odontol Bras 2002;16:189–194. computed tomography in orthodontics: benefits and limitations.
J Orofac Orthop 2005;66:434–444.
28. Liang X, Lambrichts I, Sun Y, et al. A comparative evaluation of
cone beam computed tomography (CBCT) and multi-slice CT 47. von See C, Bormann KH, Schumann P, Goetz F, Gellrich NC,
(MSCT). Part II: On 3D model accuracy. Eur J Radiol Rucker M. Forensic imaging of projectiles using cone-beam
2010;75:270–274. computed tomography. Forensic Sci Int 2009;190:38–41.
29. Sears CR, Miller AJ, Chang MK, Huang JC, Lee JS. Comparison 48. Dreiseidler T, Ritter L, Rothamel D, Neugebauer J, Scheer M,
of pharyngeal airway changes on plain radiography and cone- Mischkowski RA. Salivary calculus diagnosis with 3-dimen-
beam computed tomography after orthognathic surgery. J Oral sional cone-beam computed tomography. Oral Surg Oral Med
Maxillofac Surg 2011;69:e385–e394. Oral Pathol Oral Radiol Endod 2010;110:94–100.

ª 2012 Australian Dental Association 93


M Ahmad et al.

49. Colby CC, Del Gaudio JM. Stylohyoid complex syndrome: a new Address for correspondence:
diagnostic classification. Arch Otolaryngol Head Neck Surg
2011;137:248–252.
Associate Professor Mansur Ahmad
Division of Oral and Maxillofacial Radiology
School of Dentistry
University of Minnesota
Minneapolis MN
USA
Email: ahmad005@umn.edu

94 ª 2012 Australian Dental Association