Cone Beam Computed Tomography in the

Assessment of Dental Impactions

Dania Tamimi and Khaled ElSaid
Radiographic interpretation and diagnosis of dental impactions and different
associated pathology have long posed a challenge to the clinician. Dental
impactions can occur due to pathologic or developmental factors, both of
which can be evaluated more accurately using cone beam computed tomography (CBCT) imaging. Three-dimensional localization of the impacted teeth
and determination of the type of impaction can be performed using the
multiplanar reformats of the CBCT data, as well as three-dimensional reconstruction to give the clinician a sense of the position of the teeth in the bone
and their relationship to their adjacent structures, In the event of treatment
planning for extraction, the location of vital structures can be determined
accurately. The advent of CBCT has been a monumental event for improving
the diagnostic options and capabilities of the orthodontist. Familiarity and
full utilization of its many options can provide the dentist with a valuable
treatment planning tool. (Semin Orthod 2009;15:57-62.) 2009 Elsevier Inc.
All rights reserved.

adiographic interpretation and diagnosis

of dental impactions and different associated pathology have long posed a challenge
to the clinician. Plain film radiography offers
two-dimensional (2D) representation of threedimensional (3D) structures that often lie at
various angles to the conventional axial, coronal, and sagittal planes. Localization of these
teeth is usually done using the buccal object
rule, as well as taking two radiographic images
at right angles to one another, usually a periapical and an occlusal view.1 Diagnosis and
treatment planning is often confounded with
the presence of one or more impacted teeth at
unusual relationships to the erupted dentition, as well as important anatomical land-

From 3D Diagnostix, Brighton, MA.

Conflict of interest: Dr. Tamimi is a consultant for 3D Diagnostix, who provided the 3D reconstructions of the examples used in
this article. Mr. ElSaid is the president of 3D Diagnostix.
Address correspondence to Dania Tamimi, BDS, DMSc, 3D
Diagnostix, 167 Corey Road, Suite 111, Brighton, MA 02135.
E-mail: drtamimi@3ddx.com
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1501-0$30.00/0
doi:10.1053/j.sodo.2008.09.007

marks that must be evaluated should extraction or other surgery be considered.

With the advent of cone beam computed tomography (CBCT) and its widespread use in the
dental profession, the dentists access to advanced imaging has become facilitated while significantly lowering the radiation dose to the patient, as complicated diagnostic challenges were
often sent for medical CT evaluation in the past.
CBCT can show the location of the impacted
teeth, as well as their relationship and effect on
the surrounding dentition, and the data acquired during imaging can be reformatted to
show sequential slices through the oral and maxillofacial complex in the axial, coronal, and sagittal planes. These same data can further be
manipulated to produce 3D reconstructions of
the area of interest, giving the dentist a clearer
picture of the exact location and behavior of the
teeth in question. 3D reconstruction helps eliminate the confusion often encountered when attempting to view teeth in each of the three
anatomical planes, an exercise not usually included in traditional dental training. In addition, panoramic reconstruction of the data can
be performed to give the dentist a more familiar
radiographic image to evaluate without the pres-

Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 57-62

57

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D. Tamimi and K. ElSaid

ence of distortion, magnification, or superimposition usually associated with conventional panoramic imaging.
For 3D reconstruction, CT images are converted from axial slices into a 3D image using a
series of steps. The first step is called thresholding, where a Hounsfield range (grayscale measured in Hounsfield units [HU]) of the desired
anatomy is specified. For example, if one is segmenting the mandible, a threshold between 300
HU and 1800 HU is selected. This thresholding
operation will exclude soft tissue and air from
the images. The resulting segmentation will contain some artifact due to scatter from metal objects and fillings. This artifact is cleaned in the
next step, manual cleanup, where the operator
goes through the images one by one, cutting
away the artifact and extraneous objects from
the images. Region growing is the third step,
where the operator selects a seed point within
the structure of interest that has been already
segmented in the first two steps. That seed point
will grow into the complete region of interest
(ROI). For example, region growing for the
mandible will usually remove the spine from the
segmented mask. Finally, the resulting segmentation of the individual slice is combined together by interpretation creating a 3D reconstruction.2 Examples of these images are shown
in this article.

Determining the Etiology for Dental

Impaction
Impaction implies the failure of the tooth to
erupt into the oral cavity after development of
the roots is complete (closure of the apices). A
tooth with open apices is considered unerupted until the root is fully developed. Careful radiographic examination can determine
the stage of development, and may deem an
unerupted tooth likely to become impacted if
the orientation of its long axis does not lie in the
path of eruption.
Dental impactions can occur due to two factors: (1) pathological, such as a tumor, cyst, or
local or systemic bone pathology that increases
the density of bone that can displace or impede the eruption of the tooth, and (2) developmental, such as jaw size, eruption pattern of
the teeth, supernumerary teeth, or ankylosis. Determining the reason for the impaction greatly

impacts on treatment planning, as the appropriate surgery may be included in the treatment
plan before the commencement of orthodontic
treatment.

Pathological Factors
One of the radiologic hallmarks of cysts and benign tumors is the displacement of teeth. To impede eruption, the lesion should be located coronal to the tooth. The most common odontogenic
tumors are odontomes, and 70% of them are associated with abnormalities such as impaction,
malpositioning, diastema, aplasia, malformation,
and devitalization of adjacent teeth.1 Benign cysts
and tumors that have been known to cause impaction include dentigerous cysts, odontogenic keratocysts (OKC), ameloblastomas, calcifying epithelial odontogenic cysts (CEOT), and adenomatoid
odontogenic tumors (AOT).1 Also, diseases of
bone that increase the density of the bone surrounding the tooth may cause impaction, such as
fibrous dysplasia, and syndromes associated with
multiple supernumerary teeth such as Gardners
syndrome can show impaction of these teeth.1,3
CBCT evaluation of impacted teeth due to such
lesions can help in localization of these teeth, as
well as assessment of the extent of change/destruction to the surrounding structures (Fig 1).

Developmental Factors
The teeth most commonly impacted, after the
third molars, are the maxillary canines. The incidence of maxillary ectopic canines occurs in
approximately 3% of the population. The distribution and location has been reported at 80%
palatally and 20% buccally. These teeth are often crowded out of the arch as they have the
longest period of development, follow the most
dubious course in their eruption, and occupy
several developmental positions in succession.
The size of the jaw and length of the arch determine how much space the dentition has to align
itself into occlusion.4 The tube shift method
(also known as the parallax technique) has been
the traditional method of locating these canines
and provides an arbitrary position and approximation of the level of difficulty for the management
of the canine. This investigative technique uses two
conventional radiographs and the location of the
tooth identified by the movement of the objects
respectively to the way in which the radiograph was

Assessment of Dental Impactions

59

Figure 1. Multiplanar reformats in the (A) axial,

(B) coronal, and (C) sagittal planes of a third molar
impacted due to a dentigerous cyst.

taken. In addition, the extent of the pathology

caused by the ectopic tooth and its surrounding
structures has also been evaluated by these radiographs.5,6 A recent report found that the use of
CBCT technology could add value to the management of patients with such anomalies.7 The authors used the technology to precisely locate the
ectopic canines and to design treatment strategies
that allowed for minimally invasive surgery to be
performed and helped to design effective orthodontic strategies (Fig 2).
The presence of supernumerary teeth, such
as a mesiodens or a fourth molar, may or may
not be associated with impaction of the teeth,
depending on the arch length and alignment of

the rest of the dentition. The most common site

for single supernumerary teeth is in the maxillary incisor area, and multiple supernumerary
teeth occur most frequently in the premolar
region, usually in the mandible.1 CBCT can help
in localization of these supernumerary teeth in
relation to the surrounding teeth and other structures by reformatting the data acquired in the
three anatomical planes and examining the teeth
in these planes, giving the diagnostic process the
added advantage of buccolingual evaluation of
each individual section without superimposition of
the adjacent teeth and structures (Fig 3).
Another reason for impaction is ankylosis,
which is characterized radiographically by a dis-

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D. Tamimi and K. ElSaid

using plain film radiography, and may warrant

the use of advanced imaging (CBCT). This imaging modality can provide a spatial picture in
three dimensions for the clinician to accurately
assess and plan treatment. 3D reconstruction of
the oral and maxillofacial complex can further aid
in evaluation by eliminating the guesswork, and
giving the clinician a clear visual aid for the position of the teeth in relation to their supporting
structures. In the case of mixed dentition, the
primary teeth can be digitally removed to evaluate
the unerupted permanent dentition (Fig 3).

Figure 2. Superior view of a three-dimensional reconstruction of the maxilla with the bone digitally removed to show the position of the horizontally impacted right maxillary canine and vertically impacted
left maxillary canine in relation to the erupted dentition. (Color version of figure is available online)

continuity of the PDL space surrounding the

tooth, thus creating an inflexible tooth-to-bone
contact causing the tooth to become impacted
or submerged.3 CBCT imaging can aid in evaluation of the orientation of the tooth and its
relation and effect on the surrounding structures (Fig 4), as well as its position in relation to
occlusion if the images are taken with the teeth
fully occluded. Actual lamina dura evaluation
may be more accurate using periapical radiography, as the evaluation of fine bone detail may
not be optimal using CBCT.

Types of Impaction
Impactions are usually evaluated by examining
the angle of the long axis of the tooth. A tooth
whose long axis lies in the horizontal or vertical
plane is called horizontally or vertically impacted respectively (Figs 2 and 5). If the long
axis is tilted with the crown closer to the midline
of the jaw than the root apex, it is mesioangularly impacted. Conversely, if the crown is further from the midline than the apex, it is
distoangularly impacted. A horizontally impacted tooth may be oriented in a manner that
aligns the axis of the tooth at a right angle to the
dentition (ie, faciolingually), and any of these
types of impactions can have a buccolingual tilt
(Fig 6). Evaluation of these teeth is complicated

Figure 3. (A) Axial view showing the position of a

horizontally impacted left mesiodens and cross-section through a vertically impacted right mesiodens.
(B) Three-dimensional reconstruction of the data
shows the superior view of the same case. The bone
and primary teeth were removed digitally to show
the position of the unerupted permanent teeth
from the superior aspect. Note the open apices of
the developing permanent dentition. (Color version of figure is available online)

Assessment of Dental Impactions

61

Figure 4. Three-dimensional reconstruction showing impaction of a right second molar due to ankylosis and its relationship to the inferior alveolar
nerve. (Color version of figure is available online)

Effect of Impacted Teeth on

Surrounding Structures
The impacted tooth may displace, impede the
eruption, and/or cause external resorption of
the adjacent teeth. Clinical reports using 3D
conventional CT scans have shown that the incidence of root resorption to the adjacent teeth
has been greater than previously thought.8 If the
impacted tooth is partially erupted, it may act as
a plaque trap facilitating the development of
caries in both it and the adjacent tooth. If the
tooth is in contact with the buccal or lingual
cortices of the jaw, it may cause thinning or
slight expansion corresponding to the anatomy
of the tooth and its follicle.

Figure 5. Frontal view of a three-dimensional reconstruction of the mandible showing a horizontally impacted canine that has migrated across the midline
and is lying inferior to the right mandibular canine.
(Color version of figure is available online)

Figure 6. Coronal view showing lingual orientation of

an impacted left third molar. The position of the inferior alveolar nerve canal can be evaluated. Note the
open apices of the developing permanent dentition.

Treatment Planning for Removal or

Manipulation of the Impacted Tooth
Once surgical intervention has been decided on,
thorough radiographic examination is needed to
determine the position of the adjacent teeth and
the important anatomical structures. The proximity of the tooth to a cortex (ie, buccal or lingual)
will determine the approach the surgeon will take.
The area must be examined for proximity to nerve
and vessel canals (such as the incisive canal/foramen of the anterior maxilla and the inferior alveolar nerve [IAN] canal and mental foramen for
mandibular third molar and premolar extraction
or manipulation). The ability of CBCT to project
these structures in three different planes decreases
the chances of injuring them and the remaining
dentition. The axial plane allows for buccolingual
assessment of the tooth position (ie, lingual vs
facial placement, proximity to a cortex, and position of the incisive canal/foramen in relation to
midline supernumeraries). The coronal plane can

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D. Tamimi and K. ElSaid

show mesiodistal tilt of the anterior teeth in addition to providing sequential cross-sectional slices
through the IAN canal for detailed evaluation of
posterior tooth proximity. The sagittal plane can
show the mesiodistal orientation of the posterior
teeth as well as the faciolingual tip of the long
access of the anterior teeth (Fig 1).
The advent of CBCT has been a monumental
event for improving the diagnostic options and
capabilities of the orthodontist. Familiarity and full
utilization of its many options can provide the
dentist with a valuable treatment planning tool.

References
1. White SC, Pharoah MJ: Oral Radiology Principles and
Interpretation. Philadelphia, Mosby, 2004

2. Bankman IN: Handbook of Medical Imaging, Processing

and Analysis. San Diego, Academic Press, 2000
3. McDonald RE, Avery DR, Dean JA: Dentistry for the child
and adolescent. Philadelphia, Mosby, 2004
4. Fonseca LC, Kodama NK, Nunes FCF, et al: Radiographic
assessment of Gardners syndrome. Dentomaxillofac Radiol 36:121-124, 2007
5. Kau CH, Richmond S, Palomo JM, et al: Three-dimensional cone beam computerized tomography in orthodontics. J Orthod 32:282-293, 2005
6. Chaushu S, Chaushu G, Becker A: The role of digital
volume tomography in the imaging of impacted teeth.
World J Orthod 5:120-132, 2004
7. Mah J, Enciso R, Jorgensen M: Management of impacted
cuspids using 3-D volumetric imaging. J Calif Dent Assoc
31:835-41, 2003
8. Ericson S, Kurol PJ: Resorption of incisors after ectopic
eruption of maxillary canines: a CT study. Angle Orthod
70:415-423, 2000