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Cone Beam Computed Tomography (CBCT) for Diagnosis and Treatment Planning in Periodontology: a Systematic Review

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Cone Beam Computed Tomography (CBCT) for Diagnosis and Treatment Planning in Periodontology: a Systematic Review QUINTESSENCE INTERNATIONAL PERIODONTOLOGY Clemens Walter Cone beam computed tomography (CBCT) for diagnosis and treatment planning in periodontology: A systematic review Clemens Walter, PD Dr Med Dent1/Julia C. Schmidt, Dr Med Dent2/Karl Dula, Prof Dr Med Dent3/ Anton Sculean, Prof Dr Med Dent, MS, Dr hc4 Objective: The improvement in diagnostic accuracy and opti- aspects related to vertical bony defects. Two studies show a mization of treatment planning in periodontology through the high accuracy of CBCT in detecting intrabony defect morphol- use of three-dimensional imaging with cone beam computed ogy when compared to periapical radiographs. Particularly, in tomography (CBCT) is discussed controversially in the litera- maxillary molars, CBCT provides high accuracy for detecting ture. The objective was to identify the best available external furcation involvement and morphology of surrounding peri- evidence for the indications of CBCT for periodontal diagnosis odontal tissues. CBCT has demonstrated advantages, when and treatment planning in specific clinical situations. Data more invasive treatment approaches were considered in terms Sources: A systematic literature search was performed for of decision making and cost benefit. Within their limits, the articles published by 2 March 2015 using electronic databases available data suggest that CBCT may improve diagnostic and hand search. Two reviewers performed the study selec- accuracy and optimize treatment planning in periodontal tion, data collection, and validity assessment. PICO and PRISMA defects, particularly in maxillary molars with furcation involve- criteria were applied. From the combined search, seven studies ment, and that the higher irradiation doses and cost-benefit were finally included. Conclusion: The case series were pub- ratio should be carefully analyzed before using CBCT for peri- lished from the years 2009 to 2014. Five of the included publi- odontal diagnosis and treatment planning. (Quintessence Int cations refer to maxillary and/or mandibular molars and two to 2016;47:25–37; doi: 10.3290/j.qi.a34724) Key words: cone beam computed tomography, decision making, diagnosis, furcation involvement, furcation surgery, regenerative periodontal surgery, three-dimensional imaging Dental cone beam computed tomography (CBCT) pro- 1 Director of Postgraduate Program in Periodontology, Department of Periodon- tology, Endodontology and Cariology, University of Basel, Basel, Switzerland. vides good image quality with less radiation exposure 2 Postgraduate Student, Department of Periodontology, Endodontology and than conventional CT devices.1,2 Recently, several appli- Cariology, University of Basel, Basel, Switzerland. cations have been discussed in dentistry and guide- 3 Associate Professor, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland. lines for indications and use were published.1-3 How- 4 Professor and Chairman, Department of Periodontology, School of Dental Med- ever, CBCT diagnostic accuracy has mostly been veri- icine, University of Bern, Bern, Switzerland. fied in detection and quantification of periodontal Correspondence: Professor Anton Sculean, Department of Periodon- defects in in-vitro settings, particularly on human tology, School of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010 Bern, Switzerland. Email: [email protected] skulls.4-7 VOLUME 47 • NUMBER 1 • JANUARY 2016 25 QUINTESSENCE INTERNATIONAL Walter et al Increased pocket probing depths (PPD) are fre- Severely compromised molars with FI have an quently related to the presence of intrabony (angular) increased risk of additional vertical and horizontal periodontal defects which, when left untreated, have attachment loss, probably leading to an impaired long- been shown to worsen long-term tooth prognosis.8 term prognosis and tooth loss.15 It is well known that Findings from clinical studies have shown that peri- maxillary molars respond less favorably (in terms of odontal surgery involving various types of access flaps remaining increased periodontal pockets) to nonsurgi- and use of different biomaterials may result in PPD cal periodontal treatment.17,18 In addition, it has been reduction, hard tissue fill or even complete elimination demonstrated that PPD of ≥ 6 mm require further ther- of the intrabony component.9 It has been demon- apy in order to reduce or eliminate ongoing loss of strated that the healing of intrabony defects is strongly periodontal attachment.19 Therefore, particularly in dependent upon defect anatomy (ie, contained type molars there is a need for further treatment (Fig 1). In defects reveal a higher healing potential compared to order to select the appropriate surgical treatment defects with a more complicated non-contained anat- option, a thorough diagnosis is required, which com- omy). Thus, in order to improve the clinical outcomes, prises the estimation of the bony component, the it is recommended that the used surgical technique degree of horizontal and vertical FI, the assessment of and the choice of regenerative materials or combina- the residual inter- and periradicular bone, and the tion thereof should be based on the accurate analysis evaluation of the root morphology. Clinical diagnosis is of defect anatomy.10 When considering regenerative generally based on PPD, probing attachment level periodontal surgery, the preoperative diagnosis and (PAL), probing of the furcation entrance, and periapical evaluation of the outcomes are made by means of peri- radiographs.20 Accurate analysis of the defect morphol- odontal probing, periapical radiographs, and bone ogy, however, is not feasible in many instances due to sounding. Since periodontal probing is strongly depen- limited access, morphologic variations, and measure- dent on factors such as tissue inflammation, probe type ment errors.15 Since conventional 2D radiographic and diameter, probing force, and angulation of the imaging may have some relevant drawbacks, it might probe, the measured values may under- or overesti- be useful to analyze distinct clinical situations, particu- mate the real defect depth.11 Periapical radiographs larly vertical bony defects and maxillary molar teeth, provide only a two-dimensional (2D) image, are difficult with a three-dimensional (3D) diagnostic approach. to standardize, and may underestimate the depth and The purpose of the present systematic review was the configuration of the intrabony defect.12 Thus, there to identify the best available evidence for the indica- is a need for more accurate methods to adequately tions of CBCT for periodontal diagnosis and treatment diagnose the anatomy of intrabony defects in order to of specific clinical situations, with respect to accuracy optimize treatment planning and to enable a more and a potential benefit of dental CBCT. objective evaluation of the outcomes following regen- The specific questions in this systematic review erative surgery. were addressed according to the PICO (Patient, Inter- Multiple factors influence the prognosis of furca- vention, Comparison, Outcomes) criteria:21 tion-involved teeth, including:13-16 1. In patients suffering from periodontitis (P), which • tooth-related factors such as furcation involvement accuracy (O) of dental CBCT can be expected in (FI) degree III, and bone loss at the initiation of peri- assessing (maxillary) molars with FI when compared odontal therapy to findings obtained from clinical measurements (C)? • factors related to the dentition such as the number 2. In patients suffering from periodontitis (P), which of molars remaining accuracy of dental CBCT (O) can be expected in • patient-related factors such as smoking habits, and assessing vertical bony defects when compared to the applied treatment modality. findings obtained from clinical measurements (C)? 26 VOLUME 47 • NUMBER 1 • JANUARY 2016 QUINTESSENCE INTERNATIONAL Walter et al Figs 1a to 1d A 51-year-old woman with generalized advanced chronic periodontitis. Fig 1a Periodon- tal status of maxil- lary left teeth in advance of retreat- Fig 1b Periapical radiograph of the maxillary left first and sec- ment after system- ond molars. Interradicular bone loss and the amount of residual atic nonsurgical periodontal attachment of each maxillary molar root is not clear- periodontal thera- ly discernible. 3D imaging was performed in order to gather py 14 years previ- additional necessary information on the anatomy and to define ously.40 further periodontal treatment.15 c d Figs 1c and 1d CBCT images with horizontal, sagittal, and transversal sections (3D Accuitomo 60, XYZ Slice View Tomograph; J Morita). The maxillary left first molar (c) exhibited FI degree III in all furcations and significant loss of the interradicular bone and the proximal bone shared with the maxillary left second molar. It was decided to extract the maxillary left first molar (GoI degree 5) due to the extensive periodontal breakdown and the limited prognosis of this tooth.15 In contrast, the maxillary left second molar showed a single root with sufficient bone support with the opportunity for tooth retention in the long term. An open flap debridement with distal wedge excision (GoI degree 1) was planned for the maxillary left second molar.41 VOLUME 47 • NUMBER 1 • JANUARY 2016 27 QUINTESSENCE INTERNATIONAL Walter et al Figs 1e to 1j A 51-year-old woman with generalized advanced chronic periodontitis. Fig 1e Presurgical view of the maxillary left first and second molars. Fig 1f Incisions on the buccal and the palatal
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