Intraoperative Endodontic Applications of Cone-Beam

Computed Tomography
Randy L. Ball, DMD, Joao V. Barbizam, DDS, MS, PhD, and Nestor Cohenca, DDS
Abstract
Introduction: The use of cone-beam computed tomog-
raphy (CBCT) in endodontics for diagnosis, treatment
planning, and follow-up has been extensively reported
in the literature. Compared with the traditional spiral
computed tomography, high-resolution limited CBCT
results in a fraction of the effective absorbed dose of
radiation. However, it should be prescribed only after
weighing the cost of radiation exposure with the benet
of the diagnostic information that can be obtained from
the scan. Methods: The purpose of this article is to
discuss the application and advantages of intraoperative
CBCT in endodontics, while reducing radiation exposure
during complex endodontic procedures. Results: In
cases of increased difculty or intraoperative complica-
tions such as complex anatomy, dystrophic calcica-
tions, root resorptions, perforations, and root
fractures, it is prudent to consider the use of CBCT
with its inherent diagnostic value and limited radiation
exposure. Conclusions: The benets of the added diag-
nostic information provided by intraoperative CBCT
images in select cases justify the risk associated with
the limited level of radiation exposure. (J Endod
2013;39:548557)
Key Words
CBCT, cone-beam computed tomography, diagnosis, in-
traoperative, root canal treatment
S
ince the rst cone-beam volumetric tomography unit was approved for dental use in
the United States in 2000 (1), numerous endodontic applications of this technology,
along with cone-beamcomputed tomography (CBCT), have been described in the liter-
ature. Most of these applications are focused on preoperative assessment and treatment
planning and include diagnosis and canal morphology (24), assessment of internal
(2, 4, 5) and external root resorption (4, 6, 7), treatment planning and assessment
of traumatic dental injuries (7, 8), assessment of root fractures (2, 9), presurgical
anatomic assessment (2, 4), and treatment planning for tooth anomalies such as
dens invaginatus (10, 11). Comparison studies have shown CBCT to be more
accurate than conventional periapical radiographs in measurement of the length of
root llings (12) and diagnosing the presence of resorption lesions (1315),
periapical bone defects (1620), root fractures (2123), and perforations (24). These
studies underscore the potential benets of CBCT in diagnosis and treatment of
endodontic problems.
In 2011, the American Association of Endodontists (AAE) and the American
Academy of Oral and Maxillofacial Radiology (AAOMR) issued a joint position statement
regarding the use of CBCT in endodontics (25). The statement emphasizes that the use
of CBCT should be prescribed only after weighing the risks of radiation exposure with
the benet of the diagnostic information that can be obtained from the scan. Also, CBCT
should never be routinely used in every case with every patient, and its prescription
should only occur after a thorough clinical examination. In certain circumstances,
however, use of limited eld of view (FOV) CBCT may actually reduce the potential radi-
ation exposure of the patient during the course of endodontic treatment. The statement
notes that the use of limited eld of view CBCT systems can provide images of several
teeth from approximately the same radiation dose as two periapical radiographs, and
they may provide a dose savings over multiple traditional images in complex cases
(25). Situations occur during the course of endodontic treatment that may require addi-
tional diagnostic information to provide the best outcome for the patient. Use of CBCT in
place of multiple periapical radiographs to obtain this needed information not only
provides more accurate assessment but also reduces patient exposure to radiation.
One indication cited in the joint position statement of the AAE and AAOMR for the
use of CBCT in endodontics was intra- or post-operative assessment of endodontic
treatment complications, such as overextended root canal obturation material, sepa-
rated endodontic instruments, calcied canal identication, and localization of perfo-
rations (25). Such intraoperative use of CBCT aids in avoidance of iatrogenic mishaps,
which greatly inuence the outcome of endodontic treatment. The overall prognosis of
endodontically treated teeth has been shown to decrease because of perforations (26
29), presence of periradicular radiolucency (2931), and overll or underll of
obturation materials (32, 33). Fracture resistance of endodontically treated teeth has
also been shown to decrease when excessive tooth structure has been removed
during endodontic treatment (34). Judicious use of intraoperative limited FOV CBCT
images may prevent the occurrence of iatrogenic mishaps and reduce removal of
healthy tooth structure when anatomy of the tooth is not fully apparent on standard peri-
apical radiographs.
Intraoperative applications of CBCT include the following: location of calcied
canals, evaluation of unexpected anatomic ndings, evaluation of missed canals in
endodontic retreatment, evaluation of root resorption and root fractures, and assess-
ment of iatrogenic errors such as perforation, fractured instruments, and extruded
obturation materials. The purpose of this article is to discuss the application and
From the Department of Endodontics and Pediatric
Dentistry, School of Dentistry, University of Washington, Seat-
tle, Washington.
Address requests for reprints to Dr Nestor Cohenca, Depart-
ment of Endodontics, University of Washington, Box 357448,
Seattle, WA 98195-7448. E-mail address: cohenca@uw.edu
0099-2399/$ - see front matter
Copyright 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.11.038
Case Report/Clinical Techniques
548 Ball et al. JOE Volume 39, Number 4, April 2013
advantages of intraoperative CBCT in endodontics, while reducing radi-
ation exposure during complex endodontic procedures.
Interpretation of Root Canal Anatomy
Case 1: Determination of Second Mesiobuccal Canal in
Maxillary Second Molar
A 41-year-old woman was referred for consultation and treatment
of her maxillary right second molar. Clinical and radiographic exami-
nation was performed, and a diagnosis of pulp necrosis and symptom-
atic apical periodontitis was obtained. Initial radiographic examination
was performed with RVG 6100 digital sensors (Carestream, Atlanta, GA)
and included 2 periapical radiographs and a bite-wing radiograph.
Periapical radiolucencies were evident around the palatal (P) and dis-
tobuccal (DB) root apices (Fig. 1A). On access, the mesiobuccal (MB),
DB, and P canals were located by using a dental operating microscope
(DOM), and working lengths were obtained. Mueller burs (Brasseler
USA, Savannah, GA) and ProUltra Endo Tip #2 (Dentsply Tulsa, Tulsa
OK) were then used to trace the MB groove in an attempt to localize
the second MB (MB2) canal. Despite all clinical efforts, no MB2 was
identied. The tooth was sealed by using Cavit (3M ESPE, Seefeld,
Germany), rubber dam was removed, and the patient was scanned
with limited FOV CBCT at 76 mm (Kodak 9000; Carestream) (Fig. 1B
and C). Careful examination of the CBCT study revealed that MB2 was
not present. Periradicular radiolucencies were conrmed at the apices
of MB, DB, and P canals. Nonsurgical root canal treatment was
completed on #2 (Fig. 1D).
Case 2: Taurodontism
A 34-year-old man was referred for consultation and treatment of
the maxillary right rst molar. The patients chief complaint was
discomfort in the maxillary right posterior quadrant with cold sensitivity
during the past few weeks. Clinical and radiographic examination was
performed, and a diagnosis of symptomatic irreversible pulpitis and
symptomatic apical periodontitis was obtained. Initial radiographic
examination was performed with RVG 6100 digital sensors (Care-
stream) and included 2 periapical radiographs and a bite-wing radio-
graph (Fig. 2A and B). The periapical radiograph revealed a deep
furcation consistent with a taurodontism. On isolation and access,
caries was removed, and the pulp chamber was exposed. A C-shaped
root canal anatomy was initially diagnosed with 4 root canal orices.
However, patency was not achieved in all canals. At this point, the
need for intraoperative CBCT was indicated to further evaluate the
root canal morphology and possible intracanal and intercanal connec-
tions. The patient was informed, and consent was obtained. The tooth
was then temporarily sealed by using Cavit, rubber dam was removed,
and the patient was scanned with limited eld of view CBCT at 76 mm
(Kodak 9000) (Fig. 3).
Analysis of the CBCT scan conrmed the anatomy of taurodontism
(Fig. 3A) as well as the presence of maxillary mucositis in relationship
with the maxillary right rst molar (Fig. 3B and C). Axial cuts showed
the presence of 4 canals (Fig. 3D) with fusion of the DB and P roots,
creating the C-shape anatomy (Fig. 3D). With this information, the
nonsurgical therapy was successfully completed (Fig. 4A), and a perma-
nent core buildup was performed (Fig. 4B).
Figure 1. (A) Preoperative periapical radiograph of maxillary right second molar depicts radiolucent lesions around the P and buccal roots. (B and C) Intra-
operative CBCT demonstrates absence of MB2 in MB root (arrows) in both axial and coronal planes. (D) Postoperative periapical radiograph of nonsurgical root
canal treatment.
Figure 2. (A and B) Preoperative periapical and bite-wing radiographs of maxillary right rst molar depict anatomic pattern consistent with taurodontism,
including a deep furcation and large pulp chamber. Distal caries were noted on both images.
Case Report/Clinical Techniques
JOE Volume 39, Number 4, April 2013 Intraoperative Endodontic Applications of CBCT 549
Calcied Canals
Case 3: Localization of Palatal Canal on a Maxillary Molar
A 51-year-old woman was referred for consultation and treatment
of the maxillary right rst molar. On the basis of a comprehensive clin-
ical and radiographic examination, the tooth was diagnosed with pulp
necrosis and symptomatic apical periodontitis. Periapical radiographs
showed widening of the periodontal ligament space and loss of lamina
dura, with diffuse periradicular radiolucency around the DB root
(Fig. 5A). On isolation and access, the MB1 and DB were located by
using a DOM. No MB2 was identied clinically under the operating
microscope. The P canal presented with dystrophic calcications,
and patency was not achieved. The tooth was temporarily sealed by
using Cavit, rubber dam was removed, and the patient was scanned
with limited FOV CBCT at 76 mm (Kodak 9000) (Fig. 5BD). Analysis
of the CBCT scan revealed the exact location and orientation of the P
canal, which was calcied up to 5 mm from the radiographic apex.
The presence of periradicular radiolucencies was observed on the
MB, DB, and P roots. No MB2 was identied on the coronal and axial
cuts. By using the information obtained on the CBCT scan, corrective
clinical measures were taken to locate the P canal by using ultrasonic
instruments. All root canals were cleaned, disinfected, and lled without
complications (Fig. 5E).
Establishing the Clinical Boundaries of Therapy
Case 4: Evaluation of the Extent of Calcication of Buccal
Canal in a Maxillary First Premolar
A 64-year-old woman was referred to the predoctoral endodontics
clinic for root canal therapy on the maxillary left rst premolar. After
Figure 3. (A) Sagittal CBCT image of maxillary right rst molar demonstrating extent of pulp chamber extension and depth of furcation. (B and C) Sagittal image
with extent of mucositis in the sinus measured. (D and E) Axial images demonstrating C-shaped anatomy and presence of 4 canal systems.
Figure 4. (A and B) Postoperative periapical radiographs demonstrating completion of nonsurgical root canal therapy and core buildup placement on maxillary
right rst molar.
Case Report/Clinical Techniques
550 Ball et al. JOE Volume 39, Number 4, April 2013
clinical tests were performed and periapical radiographs were taken
(Fig. 6A), a diagnosis of pulp necrosis with normal apical tissues was
given. Upon access and caries removal, the P canal was located, but
the dental student was unable to locate the buccal canal, and the case
was referred to the graduate endodontic clinic. An intraoperative limited
FOV CBCT scan at 76 mm(Kodak 9000) was taken and analyzed (Fig. 6B
and C). The axial and coronal cuts revealed the location of the buccal
root, but no evidence of a patent canal was noted along the length of
the buccal root. The decision was made to treat the lingual canal only
and leave the buccal root intact, thereby avoiding unnecessary removal
of tooth structure and/or perforation. Nonsurgical root canal treatment
was completed on the lingual root of the maxillary left rst premolar
(Fig. 6D).
Root Resorption
Case 5: Diagnosis of External Inammatory Root
Resorption and Extent of Crown Root Fracture
A 61-year-old woman was referred for consultation and treatment
of the maxillary right rst molar. Her dental history included
Figure 5. (A) Preoperative periapical radiograph #3. (BD) Intraoperative CBCT images conrming the presence of P canal associated with periradicular radio-
lucency. Arrows indicate the level and orientation of access achieved by the operator. (E) Postoperative periapical radiograph depicting completion of endodontic
treatment #3 and obturation of P root.
Figure 6. (A) Preoperative periapical radiograph #12 depicts large carious lesion beneath existing gold onlay and calcied canals. (B and C) Intraoperative CBCT
scan demonstrates complete obliteration of buccal canal (arrows). (D) Postoperative periapical radiograph of nonsurgical root canal treatment of lingual canal.
Case Report/Clinical Techniques
JOE Volume 39, Number 4, April 2013 Intraoperative Endodontic Applications of CBCT 551
orthognathic surgery 43 years prior and endodontic access of the maxil-
lary right rst molar 2 months prior. Clinical examination revealed no
response to thermal tests, with tenderness to palpation, percussion, and
biting. During the periodontal examination a localized 5-mm pocket
was probed on the mesial aspect of the maxillary right rst molar. All
other probing depths were less than 3 mm. There was no evidence of
sinus tracts or soft tissue swelling. Preoperative radiographs were taken
with digital sensors (Kodak RVG 6100) and included 2 periapical and 1
bite-wing radiographs (Fig. 7D). Loss of lamina dura and widened peri-
odontal ligament space were noted on the MB and DB roots, with
a diffuse periradicular radiolucency of 3 mm in diameter around the
distal root. The P and DB roots were shortened and had the radio-
graphic appearance of external inammatory root resorption. The
maxillary right rst molar was diagnosed as previously initiated therapy
and asymptomatic apical periodontitis. On access, 4 canal orices were
identied (MB1, MB2, DB, and P) by using a DOM. An intracoronal
crack was also noted that extended down the mesial and distal aspects
beneath an existing amalgam restoration (Fig. 7A and B). The amalgam
restoration was removed, and it appeared that the cracks did not extend
beyond the level of the canal orice, although the 5-mm mesial peri-
odontal pocket indicated possible crack propagation. Patency of all
canals was conrmed with an electronic apex locator, and a periapical
radiograph with patency les in all 4 canals was taken (Fig. 7E). The
les in the mesial canals appeared 23 mm short of the radiographic
apex, and the le in the P canal appeared 34 mm short of the radio-
graphic apex. An intraoperative CBCT scan was taken to evaluate extent
of fracture as well as the accuracy of the working lengths (Fig. 7GJ).
Mesial crestal bone loss was not noted on the CBCT scan. Also, the
foramina of the mesial canals exited short and both buccal and lingual
to the anatomic apex by 23 mm. Progressive external root resorption
was apparent at the apex of the P canal, and the foramen exited 34 mm
coronal to the apical extent of the P root, possibly because of the resorp-
tion. These ndings explained the discrepancy in the patency le lengths
fromthe radiographic apices of the mesial and P roots. Nonsurgical root
canal treatment was completed on the maxillary right rst molar,
a composite resin core buildup was placed in the access, and an ortho-
dontic band was placed around the tooth as a temporary measure to
prevent further propagation of the crack (Fig. 7C and F). The patient
was referred back to her primary care dentist with a recommendation
for full cuspal coverage restoration.
Separated Instruments
Case 6: Determining the Location of a Separate
Instrument to Enable Bypass and Removal
A 38-year-old man presented for evaluation and treatment of his
mandibular right rst molar. Dental history revealed a previous attempt
to perform a root canal retreatment 1 week prior. The endodontist ac-
cessed the tooth and attempted to loosen the separated instrument in the
MB canal by using ultrasonics tips and les without positive outcome. At
this point, the endodontist sealed the access with Cavit (Fig. 8A) and
referred the case to a different endodontist. On initial consultation,
the patient was symptomatic and frustrated with the fact that the instru-
ment was not removed. A CBCT scan was prescribed to (1) determine
possible spaces for ultrasonic activation without risks of stripping or
perforation, (2) evaluate the location of the mental foramen to deter-
mine the feasibility of apical surgery in case the le was deemed unre-
trievable, and (3) diagnose the size and location of the apical
resorption. Analysis of the scan revealed a clear space between the
instrument and the lingual wall of the MB canal (Fig. 8AD). Inciden-
tally, a clear intracanal root resorption, presumably inammatory, was
also observed. With this information available, the second endodontist
Figure 7. (A and B) Intraoperative photographs depicting crack lines (arrows) on mesial and distal aspects of pulp chamber. (C) Postoperative photograph
demonstrating composite resin core buildup and orthodontic band cemented in place. (D) Preoperative periapical radiograph demonstrating resorption of
DB and P roots and radiolucent lesions around DB and MB roots. (E) Intraoperative periapical radiograph demonstrating patency les in all canals. The les
in the mesial and palatal canals are several millimeters short of the radiographic apices. (F) Postoperative radiograph demonstrating completed endodontic treat-
ment. (G and H) Intraoperative CBCT scan demonstrating extent of P root resorption (arrows) and (I) apical foramen of MB canals exiting short of anatomic apex
(arrows). (J) No evidence of crestal bone loss caused by fractures.
Case Report/Clinical Techniques
552 Ball et al. JOE Volume 39, Number 4, April 2013
accessed the tooth and bypassed and removed the instrument. Once this
obstruction was removed, all efforts were aimed at debriding and dis-
infecting the resorptive defect at the apical third to achieve disinfection
of this niche. Failure to do so would have likely affected the outcome of
the root canal retreatment, despite the successful removal of the sepa-
rated instrument. The nonsurgical root canal retreatment was then
successfully completed (Fig. 8E), and the patient returned asymptom-
atic at the 3-month follow-up, with radiographic evidence of healing in
process (Fig. 8F).
Vertical Root Fracture
Case 7: Differential Diagnosis of Vertical Root Fracture
A 67-year-old woman presented for examination and
endodontic treatment of her maxillary right second premolar.
The patient was complaining of dull pain in the maxillary right
posterior quadrant that started 2 weeks prior. Patient reported
having endodontic therapy on the maxillary right second premolar
more than 20 years ago. Clinical examination revealed no response
to thermal tests, with tenderness to palpation, percussion, and
biting. Periodontal examination was within normal limits, with no
probing depths of more than 3 mm. There was no evidence of sinus
tracts or soft tissue swelling. Preoperative periapical radiographs
were taken with RVG 6100 digital sensors (Fig. 9A and B). Loss
of lamina dura and widened periodontal ligament space were noted
with diffuse periradicular radiolucency. Accordingly, the maxillary
right second premolar was diagnosed as previously treated with
symptomatic apical periodontitis. The existing full crown restora-
tion was passively lifted, and the silver cones were removed by
using ultrasonic and Hedstrom les. Working length was obtained,
and canals were irrigated. Under the DOM, a possible fracture on
the palatal aspect of the buccal root was noted. The canal was
stained with methylene blue, but no denitive diagnosis was
possible. The tooth was temporarily sealed by using Cavit, rubber
dam was removed, and the patient was scanned with limited FOV
CBCT at 76 mm (Kodak 9000) (Fig. 9C and D). Analysis of the
study conrmed the presence of a root fracture on the buccal
root of the maxillary right second premolar. The patient was
referred for extraction and rehabilitation.
Case 8: Differential Diagnosis of Additional Canals or
Vertical Root Fracture
A 64-year-old woman presented for examination and endodontic
treatment of her maxillary right second premolar. Comprehensive clin-
ical and radiographic examination was performed, and the tooth was
diagnosed as previously treated with symptomatic apical periodontitis
(Fig. 10A and B). No deep periodontal pockets were diagnosed. On
access, the root canal lling was removed, and a lingual projection
was observed; the possibility of a second canal or root was discussed
with the patient. The tooth was temporarily sealed by using Cavit, rubber
dam was removed, and the patient was scanned with limited FOV CBCT
at 76 mm (Kodak 9000) (Fig. 10CE). Careful interpretation of the
CBCT images revealed the presence of a vertical bone loss along the
lingual aspect of the root (Fig. 10C) and a root fracture on the lingual
side of the maxillary right second premolar (Fig. 10D). The endodontic
procedure was not completed, and the patient was referred for extrac-
tion and rehabilitation.
Figure 8. (A) Preoperative periapical radiograph of mandibular right rst molar depicting separated instrument in MB canal. (BD) Intraoperative axial, sagittal,
and coronal CBCT images demonstrate location of separated instrument and location of apical internal resorptive defect (arrows). (E) Postoperative periapical
radiograph of nonsurgical root canal treatment performed on mandibular right rst molar, including obturation of apical resorptive defect. (F) Periapical radio-
graph taken at 3-month recall visit showing evidence of apical healing.
Case Report/Clinical Techniques
JOE Volume 39, Number 4, April 2013 Intraoperative Endodontic Applications of CBCT 553
Management of Iatrogenic Root Perforation
Case 9: Location of Mesiolingual Perforation and MB
Root Canal in a Mandibular Second Molar
A 73-year-old woman was referred for consultation and endodontic
treatment of the mandibular right second molar. Clinical and radio-
graphic examination was performed, and the tooth was given a pulpal
and periradicular diagnosis of symptomatic irreversible pulpitis and
symptomatic apical periodontitis (Fig. 11A). There was no evidence of
sinus tracts or soft tissue swelling, and all periodontal probing depths
were less than 3 mm. Endodontic treatment was initiated, and occlusal
access was performed. The distal canal and 1 mesial canal were located.
A lingual perforation occurred while searching for the second mesial
canal, and a periapical radiograph was immediately taken to conrm
the perforation (Fig. 11B). A small amount of mineral trioxide aggregate
(MTA) (Pro Root; Dentsply, Tulsa Dental, Johnson City, TN) was placed
over the perforation to seal it and prevent further contamination. The
access was temporarily sealed, and an intraoperative CBCT scan (Kodak
9000) was taken to evaluate the location of the perforation as well as the
location of the second mesial canal (Fig. 11CF). By using the intraoper-
ative CBCT images, the location and relationship of the perforation with
the crestal bone were determined, and the precise location of the MB
canal was identied. Taking into consideration the location of the perfo-
ration, the MTA seal was removed, and the perforation was repaired with
Geristore (Denmat, Santa Maria, CA). The root canal was then completed
without further complications (Fig. 11G).
Discussion
Accurate diagnostic imaging is an essential part of endodontic
evaluation and treatment. Conventional two-dimensional radiographs
are still the most widely accepted and used imaging modality in
endodontics. This is despite the fact that classic and current literature
has highlighted the limitations of conventional radiographs (16, 35
37). These limitations arise primarily because of the inherent
projection of a three-dimensional anatomy into a two-dimensional
view, which leads to geometric distortion and, consequently, misinter-
pretation and/or misdiagnosis. It has been shown that CBCT is not sub-
jected to the same limitations because of the production of accurate
three-dimensional images (16). Current literature has demonstrated
that preoperative CBCT images precisely reproduce maxillofacial tissues
(24), elucidate the presence of periapical lesions more accurately
than conventional radiographs (1620), and display the location and
extension of perforations (24), traumatic injuries (8), and resorptive
defects (7, 1416). Despite the myriad advantages that CBCT offers
compared with conventional radiographs, its use for preoperative
endodontic examination should carefully be considered on the basis
of the as low as reasonably achievable protocol concerning radiation
levels to expose patients to the least amount of radiation possible,
while still gaining the most useful information for proper diagnosis.
To date, the intraoperative use of limited FOV CBCT has not been
reported in the literature, despite the fact that it is not unusual to
encounter internal root canal anatomy that was not completely revealed
by traditional preoperative radiographs. The cases outlined in this
article exemplied clinical situations that might benet from further
imaging information to provide the best clinical care. Furthermore,
they underscore the value of taking intraoperative CBCT images to facil-
itate safe and effective endodontic treatment and to contribute to
decision-making in cases in which it may be prudent to set the bound-
aries and evaluate the benet/risk ratio that will be in the best interest of
the patients care. A good example of this clinical situation would be the
Figure 9. (A and B) Preoperative periapical radiographs of maxillary right second premolar showing presence of silver points on root canals and presence of
periradicular radiolucency. (C and D) Intraoperative coronal and axial slides after silver point removal conrming presence of root fracture on buccal root
(arrows).
Case Report/Clinical Techniques
554 Ball et al. JOE Volume 39, Number 4, April 2013
presence and clinical patency of MB2 canals in maxillary molars. As
endodontists we should always strive to treat all canals, despite the
fact that this often involves removal of additional tooth structure.
However, if the canal is not negotiable, the unnecessary removal of tooth
structure will increase the susceptibility to fracture (34) and the risk of
root perforation.
When canals are identied but are subjected to calcication, intra-
operative CBCT has been shown to be a powerful tool for assessing the
extent of calcication, thereby contributing to determining the proper
sequence of the treatment. As illustrated in the present article, CBCT
images permitted the visualization of the depth of calcications and
guided the clinician to the correct location, angle, and depth to access
Figure 11. (A) Preoperative periapical radiograph of mandibular right second molar. (B) Intraoperative periapical radiograph with le in perforation site. (CF)
Intraoperative coronal, axial, and sagittal images identifying location of perforation (arrows in C, D, and F) and MB canal (arrow in E). MTA placed over the
perforation is visible in coronal and axial views. (G) Postoperative periapical radiograph after completion of endodontic treatment and perforation repair.
Figure 10. (A and B) Preoperative periapical radiographs of maxillary right second premolar showing previous nonsurgical endodontic treatment. (CE) Intra-
operative coronal, axial, and sagittal images after gutta-percha removal conrming presence of root fracture (arrow in D) and associated bone loss on palatal
aspect of the root (arrow in C).
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JOE Volume 39, Number 4, April 2013 Intraoperative Endodontic Applications of CBCT 555
the patent portion of the canals. On the basis of accurate measurement
of the length and width of canal walls and distance from important
anatomic structures provided by the CBCT scan, the canals were found
and properly treated. On the other hand, when complete calcications
were detected, the intraoperative CBCT scan provided the critical infor-
mation that led to the decision of preserving dental structures, particu-
larly when apical pathosis is not present and the risks of attempting to
expose a completely calcied canal are unjustiable.
Vertical root fractures can be one of the most challenging diag-
nostic situations in endodontics. The cases illustrated in the present
article have demonstrated the advantage of using CBCT intraoperatively
after removal of obturation materials to diagnose root fractures. In
cases in which preoperative scans are taken, artifacts created by the
root canal lling materials would have made denitive diagnosis of these
conditions challenging. Vertical root fractures are also rarely visualized
on traditional preoperative periapical radiographs.
Precise identication of the location of a perforation can help
dictate the type of repair material used. In the case presented in this
article, the location of the perforation was identied at the height of
the crestal bone by using intraoperative CBCT images. The intraopera-
tive periapical radiograph with the le in the perforation site was not
able to provide this information. A bondable repair material (Geristore)
was chosen for nal repair to prevent washout, which might have
occurred with MTA. Also, placement of a small amount of MTA over
the perforation before intraoperative CBCT enabled exact location of
the perforation site. Accurate location of the perforation was critical
in determining management in this case.
Fromthe clinical point of view, the case series presented follows the
AAE/AAOMR recommendations of using CBCT for the assessment of
endodontic complications such as those previously mentioned. By relying
on the intraoperative CBCT images, it was possible to elucidate tooth
morphology, determine the boundaries and risks for attempting root
canal treatment in cases of calcied canals, and use them as a guide
for localization and understanding of complex endodontic anatomy. In
addition, the intraoperative CBCT scan was animportant tool for detecting
periapical pathosis, resorptive defects, extension of crack propagation,
root perforation, and vertical root fractures in cases in which the diag-
nosis or treatment was compromised by the limitations of radiographs.
In conclusion, the patient always has the right to an informed deci-
sion, especially when other diagnostic means are inconclusive. In cases of
increased difculty or intraoperative complications, it is prudent to
consider the use of limited FOV CBCT with its inherent accurate diagnostic
value and limited radiation exposure. In essence, the benets of the added
diagnostic information provided by intraoperative CBCT in select cases
justify the risk associated with the limited level of radiation exposure.
Acknowledgments
The authors acknowledge Dr Jordan West, Blake McRay, Steven
Kwan, Lindsay Posner, Harrison Nguyen, and David Mortenson for
their contribution to this manuscript.
This article was written with LCDR Randy Ball, DC, USN while
he was a resident at the University of Washington training in
endodontics. The views expressed in this article are those of the
author and do not reect the ofcial policy or position of the
Department of the Navy, Department of Defense, or the United
States Government.
The authors deny any conicts of interest related to this study.
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