American Academy of Periodontology Best Evidence Consensus Statement on Selected Oral Applications for Cone-Beam Computed Tomography

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1 J Perioontol October 2017 American Acaemy of Perioontology Best Evience Consensus Statement on Selecte Oral Applications for Cone-Beam Compute Tomography George A. Manelaris,* E. To Scheyer, Marianna Evans, i Davi Kim, # Braley McAllister,** Marc L. Nevins, # Hector F. Rios, an Davi Sarment ii Backgroun: The American Acaemy of Perioontology (AAP) recently embarke on a Best Evience Consensus (BEC) moel of scientific inquiry to aress questions of clinical importance in perioontology for which there is insufficient evience to arrive at a efinitive conclusion. This review aresses oral inications for use of cone-beam compute tomography (CBCT). Methos: To evelop the BEC, the AAP convene a panel of experts with knowlege of CBCT an substantial experience in applying CBCT to a broa range of clinical scenarios that involve critical structures in the oral cavity. The panel examine a clinical scenario or treatment ecision that woul likely benefit from aitional evience an interpretation of evience, performe a systematic review on the iniviual, ebate the merits of publishe ata an experiential information, evelope a consensus report, an provie a clinical bottom line base on the best evience available. Results: This BEC aresse the potential value an limitations of CBCT relative to specific applications in the management of patients requiring or being consiere for the following clinical therapies: 1) placement of ental implants; 2) interisciplinary entofacial therapy involving orthoontic tooth movement in the management of malocclusion with associate risk on the supporting perioontal tissues (namely, entoalveolar bone); an 3) management of perioontitis. Conclusion: For each specific question aresse, there is a critical mass of evience, but insufficient evience to support broa conclusions or efinitive clinical practice guielines. J Perioontol 2017; 88: KEY WORDS Cone-beam compute tomography; consensus; ental implants; orthoontics; perioontal iseases; raiation exposure. * Private practice, Oakbrook Terrace, Park Rige, an Chicago, IL. Department of Grauate Perioontics, University of Illinois College of Dentistry, Chicago, IL. Private practice, Houston, TX. University of Texas Dental School, Houston, TX. i Department of Orthoontics, University of Pennsylvania, Philaelphia, PA. Private practice, Newtown Square, PA. # Department of Oral Meicine, Infection, an Immunity, Division of Perioontology, Harvar School of Dental Meicine, Boston, MA. ** Private practice, Tualatin an Beaverton, OR. Department of Perioontology, Oregon Health an Science University, Portlan, OR. Private practice, Boston, MA. Department of Perioontics an Oral Meicine, University of Michigan School of Dentistry, Ann Arbor, MI. ii Xoran Technologies, Ann Arbor, MI. oi: /jop

2 Oral Applications for CBCT Volume 88 Number 10 BENEFITS OF CONE-BEAM COMPUTED TOMOGRAPHY FOR SELECTED THERAPEUTIC APPROACHES IN THE ORAL CAVITY The use of cone-beam compute tomography (CBCT) as inicate below shoul provie enhance care for patients who may require certain therapeutic approaches such as ental implants or orthoontic tooth movement. CBCT inherently offers increase iagnostic information an increase accuracy when compare to two-imensional (2D) igital (periapical an panoramic exposures) iagnostic ata. 1 This information can be valuable when consiering prognosis evaluation, treatment planning, an surgical management of complex cases that involve implant therapy or perioontal-orthoontic collaboration. 2 There is insufficient evience to ate that CBCT imaging provies ae benefit in the management of perioontitis. CBCT imaging can also be use as a communication tool with patients an with other ental-meical colleagues involve in certain cases, such as prosthoontists, peiatric entists, enoontists, orthoontists, oral an maxillofacial surgeons, otolaryngologists, sleep physicians, orofacial myologists, oral an maxillofacial raiologists, oral an maxillofacial pathologists, restorative entists, an laboratory technicians. Collaboration among all caregivers involve in complex cases may be necessary to evelop a treatment plan for optimal patient outcomes. LIMITATIONS OF CONE-BEAM COMPUTED TOMOGRAPHY FOR SELECTED THERAPEUTIC APPROACHES IN THE ORAL CAVITY Some aspects of CBCT imaging influence effective ose of raiation to the patient an are controllable by the clinician, i.e., fiel of view (FOV), time of exposure, an resolution. Other aspects of raiation exposure are intrinsic to the imaging evice or unit an beyon the clinician s control. The clinician must be aware of any limitations inherent to the CBCT unit being use. Variations in equipment an software make it ifficult to stanarize outcome measures. However, CBCT technology is evolving at a rapi pace, an improvements continue to be introuce. POTENTIAL RISKS OF CONE-BEAM COMPUTED TOMOGRAPHY FOR SELECTED THERAPEUTIC APPROACHES IN THE ORAL CAVITY Currently, the long-term raiation hazars of effective ose accumulation from CBCT are unknown. When susceptible tissues are shiele an the fiel of view is limite to the area of interest (maxilla or manible), the risk is estimate to be low. However, to minimize patient risk, aherence to juicious principles of raiation exposure is imperative. In aition, the age of the patient is a consieration in assessing risks of CBCT imaging, specifically, the consieration of cumulative raiation exposure among peiatric an aolescent patients. Clinicians shoul constantly strive to use a raiation ose as low as reasonably achievable (ALARA) to secure clinically useful iagnostic information. This is largely epenent upon the iniviual circumstances of the patient presenting for treatment. All raiographic exposures require a comprehensive iagnostic interpretation, incluing the responsibility to rule out any pathology within the FOV. CBCT ata must be rea by the practitioner within his/her realm of expertise or referre to an oral an maxillofacial raiologist or other qualifie raiologist for further analysis, interpretation, an ocumentation. FOCUSED CLINICAL QUESTION 1 Shoul CBCT imaging replace two-imensional (2D) raiographic analysis of regional anatomy in the surgical management of patients requiring ental implants? The application of CBCT in entistry has grown greatly with a clear impact on implant entistry. This consensus report is base on a review of the best available evience on this topic (Rios, Borgnakke, Benavies ) as well as expert opinion as to whether CBCT imaging shoul become the stanar of care for patients requiring ental implants. Evience Search Strategy An extensive literature search of CBCT applications in implant entistry was performe using the PubMe atabase. A total of 559 stuies publishe between January 1, 2000, an June 24, 2017, were ientifie, an 176 articles were selecte for review. These were ivie into three categories: 1) iagnosis an treatment outcome assessment, 2) implant treatment planning, an 3) anatomic characterization. It shoul be note that the systematic review i not inclue any assessment of the quality (e.g., stuy esign an potential sources of bias) of the inclue stuies. (See Rios, Borgnakke, Benavies 3 for etaile information on the literature review an results.) Consensus Conclusions The ecision about whether, an in what circumstances, to use CBCT must be mae by the clinician in light of the nees of the patient. However, current evience, preominantly from observational stuies (cohortancaseseries),supportstheuseofcbctin the surgical implant management of patients to assess the following: Evaluation of root morphology an associate pathology for extractions an reconstruction Location of relevant anatomic structures an their relation to implant placement 940

3 J Perioontol October 2017 Manelaris, Scheyer, Evans, et al. Sinus grafting preimplant evaluation Evaluation of autogenous bone onor sites Fabrication of static surgical guies an ynamic navigation of implant placement Post-bone augmentation implant planning Complications with previously place implants Team communication with implant restorative colleagues Expert opinion supports the potential applications of CBCT in the surgical management of patients requiring ental implants in the following scenarios: When there is a question regaring selection of implant sites, number, iameter, length, or loaing strategy When the patient presents with a thin phenotype or there are esthetic concerns (risk for bone or soft tissue eformities) Benefits of CBCT for Surgical Management of Patients Requiring Dental Implants Current available evience supports the conclusion that CBCT can be useful in evaluating regional anatomy as appropriate for implant planning. CBCT imaging can be inherently valuable for the following clinical uses: As a means to ientify inciental finings that may influence treatment ecisions an execution of therapy, such as periapical an other oontogenicrelate pathologies, root fractures, aberrant ental anatomy, an non-oontogenic pathologies an conitions As a vehicle to support minimally invasive therapy As a metho to eucate patients an provie information of value when obtaining patients consent for planne surgical proceures CBCT technology provies the clinician with the opportunity to improve presurgical planning as well as surgical execution through: Three-imensional (3D) presurgical anatomic measurement an virtual implant placement simulation Construction of computer-generate static surgical guies via 3D printing or stereolithography Application of ynamic surgical navigation technology Limitations of CBCT for Surgical Management of Patients Requiring Dental Implants Further research an evelopment are neee to enhance applications of CBCT technology to plan, treat, an monitor placement of ental implants. In aition, eucation in correct usage an interpretation of CBCT ata are essential to provie clinical value an assure safe use of CBCT technology. Specifically, aitional research is require to: Reuce raiation artifact, beam harening, an scatter to improve overall image resolution an quality for optimal interpretation More accurately quantify bone ensity an linear remoeling changes over time Increase availability an use of 3D printing for static guie fabrication an tissue engineering (bone augmentation) applications Minimize raiation exposure Reuce equipment costs Potential Risks of CBCT for Surgical Management of Patients Requiring Dental Implants Since the long-term raiation hazars of effective ose accumulation are unknown, aherence to juicious principles of raiation exposure is imperative to minimize patient risk. (See Potential Risks of Cone- Beam Compute Tomography for Selecte Therapeutic Approaches in the Oral Cavity above for further information.) Clinical Bottom Line on Use of CBCT for Surgical Management of Patients Requiring Dental Implants CBCT has iverse applications for ental implant therapy an shoul be use as an ajunct to 2D ental raiology when, in the reasonable jugment of the clinician, the specific benefits to the patient as outline above outweigh the risks. Avisory Provisions for Use of CBCT for Surgical Management of Patients Requiring Dental Implants The responsible use of CBCT for ental implant therapy is base on case-specific patient selection where such imaging analysis is likely to offer both a significant patient an clinician/operator benefit by proviing 3D regional anatomy information. Dental health care professionals shoul consier CBCT imaging when they expect the iagnostic information acquire will lea to better patient care, higher levels of safety, an improve clinical outcomes. FOCUSED CLINICAL QUESTION 2 Is CBCT imaging useful in etermining risk to perioontal structures in patients requiring tooth movement? CBCT imaging has emonstrate that changes occur to the buccal plate an general alveolar bone structure following orthoontic tooth movement. Expert panel members have conclue that CBCT imaging is the only raiographic moality with which such changes can be objectively etecte an preoperative 941

4 Oral Applications for CBCT Volume 88 Number 10 risk etermine. This consensus report is base on a review of the best available evience on this topic (Manelaris, Neiva, Chambrone ) as well as expert opinion relative to how CBCT imaging can be use to assess risk to the perioontium in patients requiring tooth movement. Evience Search Strategy A search of observational an interventional trials publishe in English through July 2016 that reporte on the use of CBCT imaging to assess the impact of orthoontic-entofacial orthopeic treatment on perioontal tissues was conucte. Changes in alveolar bone thickness, height aroun natural teeth, an treatment costs were evaluate an organize into evience tables. Thirteen stuies involving human patients an that recore positive or negative changes on alveolar bone surrouning natural teeth unergoing orthoontic tooth movement or being influence by orthopeic forces through fixe appliances were ientifie. The majority of the available evience for this focuse question erives from observational stuies with low methoologic quality. (See Manelaris, Neiva, Chambrone 4 for etaile information on the literature review an results.) Consensus Conclusions There is limite current evience to support specific applications of CBCT as a routine part of perioontalorthoontic treatment. However, expert opinion suggests that CBCT may be useful in the management of patients requiring perioontal-orthoontic therapy in the following scenarios: When the orthoontic patient is skeletally mature an presents with a malocclusion requiring fixe orthoontic appliances for ecompensation When the orthoontic patient has a thin entoalveolar phenotype an entoalveolar bone eficiencies are suspecte When the malocclusion patient requires avance tooth movement an there is increase risk for positioning the roots outsie of the orthoontic bounary conitions When the orthoontic patient is skeletally immature an requires an interisciplinary approach to treatment (i.e., perioontal-orthoontic-restorative or multispecialist care) When the orthoontic patient presents with concomitant mucogingival eformities (recession) When the patient presents with other specific treatment consierations requiring more global analysis (e.g., temporomanibular joint isorers, entofacial isharmonies requiring orthoonticperioontal-orthognathic approaches for management, congenitally missing teeth, or requirement for skeletal anchorage) Further, expert opinion suggests that CBCT may be useful in the management of a patient requiring other interisciplinary therapy in the following clinical scenarios: When the patient presents with impacte thir molars requiring extraction with or without potential pathologies When the patient presents with impacte teeth requiring surgical exposure an boning of an orthoontic bracket for eruption When the cleft palate patient presents for perioontalorthoontic therapy requiring ecompensation an/ or more extensive collaborative interisciplinary management When the ault patient presents with entoalveolar eficiencies (i.e., ental crowing) an/or transverse maxillary eficiencies that might require surgical intervention to help ensure orthoontic bounary conitions are respecte Benefits of CBCT Imaging for Determining Risk to Perioontal Structures in Patients Requiring Tooth Movement Expert opinion supports the use of CBCT to ientify patients unergoing orthoontic treatment who are at risk for alveolar bone (ehiscences or fenestrations) or soft tissue (recessions) eficiencies. Limitations of CBCT Imaging for Determining Risk to Perioontal Structures in Patients Requiring Tooth Movement Further research is neee to etermine how the application of CBCT impacts treatment planning, ecision making, therapies, an evaluation of outcomes. The following issues warrant further research as they relate to perioontal-orthoontic consierations evaluate by CBCT: Preventive soft tissue an bone augmentation inications an requirements Limitations to the irections an amount of tooth movement Upper airway volume an anatomic consierations as a possible ajunct to other airway measurements Alternative orthoontic applications relate to malocclusion types Surgically facilitate orthoontic therapy Skeletal malocclusions requiring ental ecompensation movements as part of comprehensive orthoontic therapy Orthognathic surgery treatment planning Other treatment consierations (temporomanibular joint isorers, congenitally missing teeth, nee for skeletal anchorage) Development of approaches to CBCT imaging that provie the best cost-to-benefit ratio 942

5 J Perioontol October 2017 Manelaris, Scheyer, Evans, et al. Potential Risks of CBCT Imaging for Determining Risk to Perioontal Structures in Patients Requiring Tooth Movement As note above, since the long-term raiation hazars of effective ose accumulation are unknown, aherence to juicious principles of raiation exposure is imperative to minimize patient risk. (See Potential Risks of Cone-Beam Compute Tomography for Selecte Therapeutic Approaches in the Oral Cavity above for further information.) Clinical Bottom Line on Use of CBCT Imaging for Determining Risk to Perioontal Structures in Patients Requiring Tooth Movement CBCT imaging can, in appropriate circumstances, improve perioontal risk assessment an assist in planning a safer approach to orthoontic therapy, particularly in the skeletally mature patient. CBCT shoul be consiere as a means to ientify those at increase risk of eveloping entoalveolar bone eficiencies relate to orthoontic tooth movement, particularly in skeletally mature patients presenting with thin perioontal phenotypes. With CBCT, clinicians an patients can be better informe regaring risk of averse sequelae relate to tooth movement. CBCT imaging can also help clinicians evelop approaches to prevent averse sequelae or plan interceptive perioontal augmentation (bone an/or soft tissue) for patients unergoing orthoontic tooth movement. Avisory Provisions of CBCT Imaging for Determining Risk to Perioontal Structures in Patients Requiring Tooth Movement CBCT exposes patients to raiation an shoul be consiere an ajunctive iagnostic metho after a comprehensive perioontal examination is performe to assess potential risks to the perioontal structures from tooth movement. In aition, the age of the patient shoul be consiere in assessing the risks of CBCT imaging an cumulative raiation exposure, especially among peiatric an aolescent patients. FOCUSED CLINICAL QUESTION 3 Does CBCT imaging a clinical value in iagnostic assessment an treatment planning for the management of perioontitis? Clinical an raiographic examinations are essential in establishing an accurate perioontal iagnosis an in suggesting appropriate treatment options. However, 2D intraoral raiographic images provie limite information, especially regaring the severity of perioontitis (e.g., furcation, intrabony efects, an buccal plate), an there is a nee to investigate alternative imaging methos. This best evience consensus report examines when CBCT imaging is appropriate for iagnostic inquiry in the management of perioontitis. This consensus report is base on a review of the best available evience on this topic (Kim an Bassir ) as well as expert opinion as to whether CBCT imaging as clinical value in the management of perioontitis. Evience Search Strategy The authors performe an extensive search of MEDLINE for stuies aime at answering the following clinically relevant questions: 1) In patients with perioontitis, what (if any) clinical situations exist where CBCT imaging improves iagnostic acumen an subsequent treatment recommenations compare to 2D raiographic interpretation? 2) Does CBCT imaging improve the accuracy of iagnosis an the establishment of a prognosis in the analysis of furcation an/or intrabony efects? Is the execution of therapy improve, facilitate, or therapeutically challenge? 3) Does the use of CBCT imaging provie superior short- or long-term clinical outcomes, more favorable patientreporte outcomes, or more consistent clinical treatment ecisions affecting tooth prognosis (as measure by efect fill, improvements in bone anatomy, mobility patterns, an ultimate tooth survival)? The electronic search ientifie 885 papers, an a manual search yiele five aitional citations. Twelve articles met inclusion criteria for etermining the role of CBCT in iagnosis an treatment of both intrabony an/or furcation efects. (See Kim an Bassir 5 for etaile information on the literature review an results.) Consensus Conclusions Current evience supports the use of 2D full-mouth raiographic series in aition to clinical probing parameters as the gol stanars for comprehensively evaluating perioontal structures. Little evience currently supports CBCT as a routine replacement or ajunct to 2D imaging in the management of perioontitis. CBCT imaging may a information for treatment planning of the full-mouth avance perioontitis case. Expert opinion suggests that CBCT may be useful in the management of patients with perioontitis accoring to the following scenarios: When an avance furcation lesion has been etecte an ental implants are being consiere as an alternative treatment option When avance bone loss has encroache on anatomic structures, such as sinus cavities or the inferior alveolar nerve When there is a questionable root fracture, root resorption, or perioontal-enoontic lesion present that coul not be ientifie by 2D imaging an/or clinical evaluation 943

6 Oral Applications for CBCT Volume 88 Number 10 In the retreatment of cases that on t respon favorably to localize perioontal therapy To enhance the iagnosis an management of peri-implantitis when etermine necessary Benefits of CBCT Imaging in the Diagnostic Assessments an Treatment Planning for the Management of Perioontitis Current available evience oes not support the routine use of CBCT in managing perioontitis. Expert opinion, however, suggests that CBCT may be a useful iagnostic ajunct to conventional 2D imaging an clinical probing in avance cases with concurrent enoontic pathologies or in patients who are being consiere for ental implant therapy. Assuming metal artifact is limite or non-existent, aitional benefits may be realize on a case-by-case basis to assess the geometric morphology of furcations or intrabony lesions to help etermine regenerative potential an associate prognostic surgical outcome. Because the management of perioontitis often requires an interisciplinary approach, such as orthoontics, avance imaging may be beneficial on a case-by-case basis epening on the iniviual nees of the patient for comprehensive management. In selecte patients, 3D imaging may also improve etermination of hopeless tooth prognosis to ai in treatment planning an improve unerstaning of efect morphology to ai in flap esign, especially as it relates to minimally invasive therapeutic approaches. Limitations for Use of CBCT for Diagnosis an Treatment Planning in the Management of Perioontitis At this time, limite evience supports the use of CBCT for the etection an characterization of furcation an intrabony efects. Further research is neee to etermine the utility of CBCT imaging in supporting minimally invasive therapies, in assessing perioontal regenerative outcomes, an in etermining the necessity of combination therapy (orthoontics, guie perioontal tissue regeneration, soft tissue grafting) in complex cases. In aition, the evelopment of new, cost-effective approaches to CBCT imaging is also inicate. Potential Risks for Use of CBCT for Diagnosis an Treatment Planning in the Management of Perioontitis As note above, since the long-term raiation hazars of effective ose accumulation are unknown, aherence to juicious principles of raiation exposure is imperative to minimize patient risk. (See Potential Risks of Cone-Beam Compute Tomography for Selecte Therapeutic Approaches in the Oral Cavity above for further information.) Clinical Bottom Line on Use of CBCT for Diagnosis an Treatment Planning in the Management of Perioontitis In select cases, as etaile above, limite-fov CBCT can a useful 3D information on perioontitis (severity an presence of efects). However, in most cases with perioontitis, CBCT imaging provies little benefit to the clinician in making ecisions on the management of perioontitis alone. Because the management of more avance forms of perioontitis often requires an interisciplinary approach to treat optimally, avance imaging may be valuable on a case-by-case basis epening on the iniviual nees an circumstances of the patient. Avisory Provisions for Use of CBCT for Diagnosis an Treatment Planning in the Management of Perioontitis Despite the fact that there is rapily accruing literature on CBCT an its potential iagnostic applications, to ate there is insufficient evience to support its use an implementation for routine perioontal treatment planning. Expert opinion, however, suggests that CBCT may have value in the management of patients with perioontitis in selecte scenarios escribe above. This represents an opportunity for aitional well-esigne clinical stuies. ACKNOWLEDGMENTS The American Acaemy of Perioontology Best Evience Consensus meeting on cone-beam compute tomography was sponsore by Carestream Dental (Atlanta, Georgia). Co-Chairs Drs. Manelaris an Scheyer share an equal role for the Best Evience Consensus. Together with the Eitor of the Journal of Perioontology, Dr. Kenneth Kornman, they woul like to thank Drs. Hugo Campos, Tufts University School of Dental Meicine; Jack Gunsolley, Virginia Commonwealth University School of Dentistry; an Davi Paquette, East Carolina University School of Dental Meicine, for their expert review of the evience basis for the consensus. Dr. Manelaris has receive lecture fees from Carestream Dental, Materialise Dental, ClaroNav, an Geistlich Pharma. Dr. McAllister has receive lecture fees from Carestream Dental. Dr. Sarment is presient of Xoran Technologies, which makes meical CBCT scanners. Drs. Scheyer, Evans, Kim, Nevins, an Rios report no conflicts of interest relative to this Best Evience Consensus statement. REFERENCES 1. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Conebeam compute tomography in implant entistry: A systematic review focusing on guielines, inications, an raiation ose risks. Int J Oral Maxillofac Implants 2014;29(Suppl.):

7 J Perioontol October 2017 Manelaris, Scheyer, Evans, et al. 2. Kapila SD, Nervina JM. Alveolar bounary conitions in orthoontic iagnosis an treatment planning. In: Kapila SD, e. Cone-Beam Tomography in Orthoontics: Inications, Insights, an Innovations. Hoboken, NJ: Wiley- Blackwell; 2014: Rios HF, Borgnakke WS, Benavies E. The use of conebeam compute tomography in management of patients requiring ental implants: An American Acaemy of Perioontology best evience review. J Perioontol 2017; 88: Manelaris GA, Neiva R, Chambrone L. Cone-beam compute tomography an interisciplinary entofacial therapy: An American Acaemy of Perioontology best evience review focusing on risk assessment of the entoalveolar bone changes influence by tooth movement. J Perioontol 2017;88: Kim DM, Bassir SH. When is cone-beam compute tomography imaging appropriate for iagnostic inquiry in the management of inflammatory perioontitis? An American Acaemy of Perioontology best evience review. J Perioontol 2017;88: Corresponence: Dr. E. To Scheyer, 3400 S. Gessner Roa, Suite 102, Houston, TX Fax: 713/ ; etsperio@periohealth.com. Submitte April 7, 2017; accepte for publication July 6,