The Untapped Potential of CBCT in Implant Surgery and Periodontal Care

It would behoove those training today’s implant surgeons to implement cone-beam computed tomography (CBCT) with greater emphasis and frequency. A survey of CBCT utilization among United States post-doctoral periodontics programs for implant planning showed that while a majority of programs train with this technology, it was still underutilized as part of guided implant therapy.¹

FIGURE 1. Cone beam computed tomography showing a virtual dental implant workup. Bone availability and quality can be assessed, as well as the location of vital structures. From this, and with appropriate software, a computer-generated surgical guide can be fabricated.Cone beam scans are also useful in surgical guide fabrication and other digital workflows, such as dynamic navigation (Figure 1). Various working platforms are available commercially in which three-dimensional bony data are merged with intraoral landmarks. The practitioner is then provided an intraoral guide, and the implant is placed with guided assistance.

DIAGNOSING AND MANAGING PERIODONTITIS

Currently, a complete periodontal assessment and a full-mouth radiographic series are still key components in establishing a periodontal diagnosis.² However, an exact measurement of the alveolar bone height and morphology using CBCT scans could enhance accuracy when assessing different periodontal conditions.³ That noted, the decision to utilize this imaging modality must be reached on a case-by-case basis, because the increased radiation exposure may not be warranted for all patients.²

There have been numerous ex-vivo studies on dry human skulls showing the increased accuracy of cone-beam imaging compared to routine periapical radiographs for detecting periodontal intrabony defects.^4-6 Misch et al⁴ found that all defects were detected by CBCT, but only 67% were noted with periapical radiographs. Vandenberghe et al⁵ further showed that all bony craters and furcation defects were seen with CBCT, compared to only 56% to 71% of bony discrepancies shown with conventional bitewing and periapical films. And still other work by Fuhrmann et al⁶ showed similar sensitivity between CBCT and other intraoral films in detecting different experimental defects, including dehiscences, fenestrations and furcation defects.

These ex-vivo studies can produce a valid reference with artificially created bony defects for detection and analysis much more reliably than what occurs naturally in the mouth. But the literature shows these ex-vivo studies should be read with caution. With a dry skull, all images are captured without the added burden of patient movement.⁷ Also, others will note that in these skull studies, all metal artifacts have usually been removed, reducing bothersome scatter, and the dehydrated skulls result in a faded cementoenamel junction, complicating the main reference point for calculating periodontal osseous defects.⁸ In summary, although interesting, the results from ex-vivo dry-skull studies should be interpreted with caution.⁹

Cone beam imaging can also detect bony abnormalities that may be missed as part of a routine clinical and radiographic assessment (Figure 2). However, there is still a lack of literature to support the use of CBCT technology to improve short- and long-term clinical outcomes of periodontal treatment.⁹ A systematic review found that while helpful in supporting the results of regenerative periodontal therapy, CBCT information may not lead to a better periodontal diagnosis.¹⁰ Overall, there is insufficient clinical evidence at this time to support the routine use of CBCT for the diagnosis and treatment of common periodontal defects.⁹

This information originally appeared in Francis JR, Siu TL. Utility of cone beam imaging in periodontics and implant therapy.  Decisions in Dentistry. 2023;9(2)16-18.

References

1. Beals DW, Parashar VP, Francis JR, Agostini GM, Gill A. CBCT in advanced dental education: a survey of U.S. postdoctoral periodontics programs. J Dent Educ. 2020; 84:301–307.
2. McAllister B, Eshraghi VT. Commentary: cone-beam computed tomography — an essential technology for management of complex periodontics and implant cases. J Periodontol. 2017;88:937–938.
3. Mol A, Balasundaram A. In-vitro cone beam computed tomography imaging of periodontal bone. Dentomaxillofac Radiol. 2008;37:319–324.
4. Misch KA, Yi ES, Sarment DP. Accuracy of cone beam computed tomography for periodontal defect measurements. J Periodontol. 2006;77:1261–1266.
5. Vandenberghe B, Jacobs R, Yang J. Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: an in vitro assessment of bony an​d/​or infrabony defects. Dentomaxillofac Radiol. 2008;37:252–260.
6. Fuhrmann RA, Bucker A, Diedrich PD. Furcation involvement: comparison of dental radiographs and HR-CT slices in human specimens. J Periodontal Res. 1997;32:409–418.
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8. Vandenberghe B, Jacobs R, Yang J. Diagnostic validity (or acuity) of 2D CCD versus 3D CBCT-images for assessing periodontal breakdown. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104:395–401.
9. Kim DM, Bassir SH. When is cone-beam computed tomography imaging appropriate for diagnostic inquiry in the management of inflammatory periodontitis? An American Academy of Periodontology best evidence review. J Periodontol. 2017;88:978–998.
10. Woelber JP, Fleiner J, Rau J, Ratka-Krüger P, Hannig C. Accuracy and usefulness of CBCT in periodontology: a systematic review of literature. Int J Periodontics Restorative Dent. 2018;38:289–297.