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Study of the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans

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Objective: The aim of this study was to identify the type and frequency of incidental findings in the maxillofacial region of cone-beam computed tomography (CBCT) scans with different sizes of field of view (FOV), and the clinical relevance of the findings were was classified as requirement or not of monitoring, treatment or referral to a specialist. Methods: We analyzed 150 CBCT exams, divided according to the size of the FOV into three groups: 6 cm maxilla, 6 cm mandible and 13 cm maxilla/mandible. The incidental findings were categorized into six areas: airway, temporomandibular joint (TMJ), bone, lesions of the jaws, teeth and soft tissue calcifications. Results: The results showed 560 incidental findings that were found in 92% of the sample studied. A total of 225 incidental findings were found in examinations of the maxilla group, 99 in the mandible group and 236 in the maxilla/mandible group. The incidental findings were most frequent in the tooth zone (27.32%), followed by airways, soft tissue calcifications, TMJ, bone, lesions of the jaw and other findings. We also found that 43.46% of the incidental findings did not need treatment or referral to another professional, 28.97% required the acquisition of new images for monitoring and 27.55% needed treatment or referral. Conclusions: The present study confirmed the high frequency of incidental findings in CBCT scans. It was concluded that it is necessary to interpret and report the total volume obtained in CBCT examinations and not only the purpose of the examination region.
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RESEARCH ARTICLE
Study of the frequency and location of incidental findings of the
maxillofacial region in different fields of view in CBCT scans
1
Ivna A Lopes,
1
Rosana M A Tucunduva,
1
Roberta H Handem and
1
Ana Lucia A Capelozza
1
Department of Stomatology, Bauru School of Dentistry, University of S~
ao Paulo, Bauru, S~
ao Paulo, Brazil
Objectives: The aim of this study was to identify the type and frequency of incidental
findings (IFs) in the maxillofacial region of CBCT scans with different sizes of field of view
(FOV), and the clinical relevance of the findings was classified as requirement or not of
monitoring, treatment or referral to a specialist.
Methods: We analyzed 150 CBCT examinations, divided according to the size of the FOV
into 3 groups: 6-cm maxilla, 6-cm mandible and 13-cm maxilla/mandible. The IFs were
categorized into six areas: airway, temporomandibular joint (TMJ), bone, lesions of the jaws,
teeth and soft-tissue calcifications.
Results: The results showed 560 IFs that were found in 92% of the samples studied. A total
of 225 IFs were found in examinations of the maxilla group, 99 findings in the mandible
group and 236 findings in the maxilla/mandible group. The IFs were most frequent in the
tooth zone (27.32%), followed by airways, soft-tissue calcifications, TMJ, bone, lesions of the
jaw and other findings. We also found that 43.46% of the IFs did not need treatment or
referral to another professional, 28.97% findings required the acquisition of new images for
monitoring and 27.55% findings needed treatment or referral.
Conclusions: The present study confirmed the high frequency of IFs in CBCT scans. It was
concluded that it is necessary to interpret and report the total volume obtained in CBCT
examinations and not only the purpose of the examination region.
Dentomaxillofacial Radiology (2016) 45, 20160215. doi: 10.1259/dmfr.20160215
Cite this article as: Lopes IA, Tucunduva RMA, Handem RH, Capelozza ALA. Study of the
frequency and location of incidental findings of the maxillofacial region in different fields of
view in CBCT scans. Dentomaxillofac Radiol 2016; 45: 20160215.
Keywords: incidental finding; CBCT; diagnostic imaging
Introduction
CBCT, used to capture images in the maxillofacial region,
was developed in the 1990s and since then, it has evolved.
This scan imaging is used in dentistry because it can
provide excellent images with high contrast of the bone
and tooth structures with lower radiation dose and low
cost for the patient compared with examinations obtained
by helical CT. Obtaining the image for CBCT still has
advantages when compared with conventional X-rays,
because it eliminates most of the problems related to im-
age distortion and superimposition of structures.
1
During the acquisition of a CBCT image, the field of
view (FOV) can be modified and determined as the
region of interest. The images obtained on a CBCT
scanner with a small FOV are used for interpreting
limited areas of the maxillofacial region, while the
images obtained with a large FOV include the paranasal
sinuses, airways and intracranial and cranial base
structures.
2
With the growing indication of CBCT in various
dental specialities, much has been asked about the role
of the dentist in evaluating the image obtained in the
examination. Although often overlooked, the evalua-
tion of all structures included in the examination is
required according to the guidelines of the American
Correspondence to: Mrs Ivna Albano Lopes. E-mail: ivnalbano@hotmail.com
Received 19 May 2016; revised 20 August 2016; accepted 5 September 2016
Dentomaxillofacial Radiology (2016) 45, 20160215
ª2016 The Authors. Published by the British Institute of Radiology
birpublications.org/dmfr
and European Academies of Dentomaxillofacial Ra-
diology. Therefore, knowledge is needed of not only
the dentomaxillary complex, but also the adjacent
structures.
3,4
As imaging techniques evolve, the ability to identify
incidental findings (IFs) increases. An IF can be defined
as a radiographic or tomographic image with any dis-
covery that is unrelated to the original purpose of the
examination, which can range from anatomical varia-
tions to benign and malignant lesions.
2
The inability to identify, inform or provide follow-
up and care related to the IFs may have negative
consequences for the patient and result in dentists
neglecting their legal responsibility.
2
The recognition
of IFs in CBCT images allows the identification of
occult lesions, thereby improving the accuracy of the
diagnosis and enabling the most appropriate thera-
peutic approach.
Research shows that when two-dimensional images
are interpreted, IFs are identified in 643% of
patients.
57
CBCT examinations contain more in-
formation than images in two dimensions, so it is to be
expected that in these examinations, the radiologist will
find higher occurrence of IFs.
Although there are some studies that have already
found many IFs in the maxillofacial region,
1,813
there
are no studies with Brazilian samples yet. In addition,
these studies did not use examinations showing different
sizes of FOV in their samples. Therefore, it would be
a great contribution to carry out more studies aimed at
recognizing the types and frequency of IFs in each type
of FOV in order to avoid underestimation or over-
estimation of substantial abnormalities.
The objectives of our study were to identify the type,
frequency and location of IFs in the maxillofacial region
of CBCT scans with different sizes of FOV and classify
the findings into the requirement or not of monitoring,
treatment or referral to another professional.
Methods and materials
This study was approved by the Ethics Committee of
the Bauru School of Dentistry, University of S~
ao Paulo.
A total of 150 CBCT examinations were selected from
the image files of the Department of Stomatology of this
institution.
The inclusion criteria for sample selection were: (1)
images with an FOV 6-cm high involving only the
maxilla; (2) images with an FOV 6-cm high involving
only the mandible; and (3) images with an FOV 13-cm
high involving both the maxilla and mandible. The ex-
clusion criteria were: examinations without reasons for
their requests and examinations with bad picture
quality.
The sample was divided into 3 groups: (1) 50 exami-
nations covering the maxilla; (2) 50 examinations cov-
ering the mandible; and (3) 50 examinations covering the
maxilla and mandible. The examinations showed varying
voxels (0.2, 0.25, 0.3 and 0.4) and the diameter of the
FOV was 16 cm.
The equipment used in this research was an i-CAT
Classic
®
(Imaging Science International, Hatfield, PA)
and for the interpretation of the examinations, i-Cat
Vision
®
software (Imaging Sciences International,
Hatfield, PA) was used on a multiplanar reformat-
ting screen.
2 researcher radiologists performed the analysis of
the examinations in 2 stages: 21 examinations (15%
of the sample) were observed first and after 15 days,
a new assessment was performed. Thus, an intra-
calibration and an intercalibration were performed
through the kappa test. Thereafter, a single dentist
radiologist examiner, followed the study and evalu-
ated all the CBCT examinations and reported the
possible IFs, which were not associated with the
reason. Findings directly related to the preliminary
indications of the CBCT were excluded. A list con-
taining the most common IFs in CBCT examinations
based on the literature
1,813
was developed for a bet-
ter classification of images. In the few cases of doubt
about the image, other experienced radiologists were
consulted.
Data about the patients (gender and age) and the
indication of each CBCT examination were also col-
lected. All diagnoses were based on CBCT findings.
Comparisons and associations with conventional radi-
ography and histopathological examinations were not
performed.
Table 1 Indications of CBCT examinations in the sample
Indications of CBCT examination
Amount
n%
Planning for implant 61 40.67
Evaluation/control of cysts/tumours 21 14.00
Pre-operative assessment of third molar 12 8.00
Unerupted tooth assessment 14 9.33
Supernumerary tooth location 6 4.00
Others 36 24.00
Total 150 100.00
Table 2 Distribution of the number of incidental findings (IFs) in accordance with the field of view (FOV) used
FOV Total number of IFs Average of findings per examination Number of examinations with findings
Maxilla 225 4.50 49
Mandible 99 1.98 42
Maxilla/mandible 236 4.72 47
Total 560 3.73 138
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The IFs were divided into six zones: (1) airway, (2)
temporomandibular joint (TMJ), (3) bone, (4) lesions of
the jaw, (5) teeth and (6) soft-tissue calcifications.
The TMJ and the airways were not analyzed in
Group 2 (mandible) because they were not visible in
this FOV. When the IF did not fit in any of the six
zones shown, it was included in the Othergroup.
Findings such as missing teeth, dental caries and bone
loss were excluded. An IF that was observed more
than once in the examination was recorded to be
observed.
After analyzing the CBCT examinations, the IFs
were classified in relation to their clinical manage-
ment into three groups: (1) does not need treatment/
referral to another professional; (2) monitoring is
suggested; and (3) needs treatment/referral to another
professional.
The descriptive and inferential analyses of the data
were performed using the Statistica v. 5.1 program (Stat
Soft Inc, Tulsa, OK) and by adopting a significance
level of 5%.
Results
Intraexaminer and interexaminer calibration
Kappa test was performed and the agreement was al-
most perfect, with a 0.87 intraexaminer calibration and
0.81 interexaminer calibration.
Sample profile
Patients in the sample were aged between 8 and 91 years
(mean 37 ± 18.3 years). The females were predominant
in the sample (n582) with 54.7% while 45.3%
were males.
Reason for requesting CBCT examination
The prevailing indication of CBCT examinations was
planning implants (n561) with a frequency of 40.67%
of the sample (Table 1).
Incidental findings
A total of 560 IFs were obtained; the maxilla/mandible
group had the largest number of IFs, followed by the
Table 3 Descriptive analysis and frequency of incidental findings (IFs) of CBCT examinations with the field of view encompassing the maxilla
Zone IFs Number (%) of IF Number of patients with IF Clinical management
a
Airway Thickening maxillary sinus mucosa 41 (18.22) 30 .2 mm: Y
Alveolar extension of the maxillary sinus 17 (7.55%) 17 N
Deviated septum 8 (3.55%) 8 Y
Cyst retention/pseudocyst/polyp 6 (2.66%) 6 N
Turbinate hypertrophy 4 (1.77%) 4 Y
Antrolith 3 (1.33%) 3 N
Thickening sphenoid sinus mucosa 3 (1.33%) 3 Y
Tuber extension of the maxillary sinus 3 (1.33%) 3 N
Bucosinusal communication 2 (0.89%) 2 Y
Total opacification of the maxillary sinus 1 (0.44%) 1 Y
Total opacification of the sphenoid sinus 1 (0.44%) 1 Y
Concha bullosa 1 (0.44%) 1 Y
Nasal polyposis 1 (0.44%) 1 N
Total 91 (40.44%) 80
TMJ Osteophytes 25 (11.11%) 17 F
Flattening condyle 24 (10.67%) 17 F
Away zone
b
12
Total 49 (21.78%) 34
Bone Palatal torus 9 (4.00%) 9 N
Bone sclerosis 2 (0.89%) 2 N
Total 11 (4.89%) 11
Lesions of the jaw Periapical cyst 4 (1.78%) 4 Y
Odontoma 1 (0.44%) 1 Y
Total 5 (2.22%) 5
Teeth Root dilaceration 16 (7.11%) 10 N
Apical lesion 9 (4.00%) 9 Y
Impacted tooth 3 (1.33%) 2 F
Pulp calcification 1 (0.44%) 1 N
Endoperio lesion 1 (0.44%) 1 Y
Condensing osteitis 1 (0.44%) 1 Y
External resorption 1 (0.44%) 1 Y
Total 32 (14.22%) 25
Soft-tissue calcifications Calcification of the stylehyoid complex 33 (14.67%) 18 N
Tonsillolith 1 (0.43%) 1 N
Total 34 (15.11%) 19
Others Residual root 2 (0.89%) 2 Y
Amalgam fragment 1 (0.44%) 1 N
Total 3 (1.33%) 3
F, need follow-up; N, do not require treatment/referral; TMJ, temporomandibular joint; Y, need treatment/referral to another professional.
a
Many findings were classified as being asymptomatic. Treatment may be changed according to the symptoms and complaints of patients.
b
It was not possible to analyze the zone because the region was not visible in the examination.
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maxilla group and the mandible group. The distribution
of the number of IFs between sample groups is shown in
Table 2. The zone with the highest number of IFs was
the teeth, with 27.32%, and the most common IF in the
sample was thickening of the maxillary sinus mucosa
(n570), with 12.5%. The frequency of IFs among the
six zones evaluated in the sample is illustrated in
Figure 2. The IFs of each group evaluated can be seen
in Tables 35.
Number of incidental findings and gender of patients
There was no statistically significant result for any zone
and gender using the MannWhitney U-test to correlate
the number of IFs with male and female gender.
Number of incidental findings and age of patients
Using Spearman correlation to correlate the age of
patients with the number of findings by zone, it was
found to be a statistically significant result that older
patients had a larger number of IFs in the soft-tissue
calcification zone (p50.001).
Clinical relevance of incidental findings
Most of the findings with a 43.46% frequency do not
require treatment or referral to another professional. A
total of 28.97% of the findings need monitoring by the
dentist and 27.97% of them need treatment or referral to
another professional. In Tables 35, the classification of
each IF is established.
Discussion
In the present study, we evaluated 150 CBCT exami-
nations performed as a complementary examination
for diagnosis in dentistry. Planning for implant place-
ment was the most frequent reason for the request for
examinations, with 40.07% of the total sample (Table 1).
This result was also reported by other authors with
52.773% of frequency.
1,10,14
The current criteria
for the prescription of images obtained by CBCT were
established by SEDENTEXCT in 2011, an evidence-
based guidelines on use of CBCT in Dentistry, in-
cluding referral criteria, quality assurance guidelines
and optimisation strategies.
The sample was divided into three groups according
to the size of the FOV in this study. This division was
aimed at differentiating the type and frequency of
findings between the dental arches. Most of the studies
of IFs in the literature are performed with a large
FOV.
10,15
Some authors do not describe the size of the
FOV,
1113
as shown in Table 6.
With regard to the profile of the sample of this re-
search, the majority of patients were female, with
54.7%, which corroborates with findings in the
literature.
1,813
With regard to age, we had a very large age range in
the sample (891 years). In the literature, there are
similar results, since in these studies there were no cri-
teria for inclusion or exclusion in relation to age
(Table 6).
1,1013,15
Table 4 Descriptive analysis and frequency of incidental findings (IFs) of CBCT examinations with the field of view encompassing the mandible
Zone IFs Number (%) of IF Number of patients with IF Clinical management
a
Bone Bone sclerosis 12 (12.12%) 9 N
Mandibular torus 1 (1.01%) 1 N
Total 13 (13.13%) 10
Lesions of the jaw Osteoma 1 (1.01%) 1 F
Dentigerous cyst 1 (1.01%) 1 Y
Odontoma 1 (1.01%) 1 Y
Total 3 (3.03%) 3
Teeth Apical lesion 10 (10.10%) 8 Y
Endoperio lesion 5 (5.05%) 3 Y
Impacted tooth 5 (5.05%) 5 F
Giroversion 4 (4.04%) 4 N
Root dilaceration 3 (3.03%) 3 N
Furcation lesion 3 (3.03%) 3 Y
Pulp calcification 2 (2.02%) 2 N
Condensing osteitis 2 (2.02%) 2 Y
External resorption 1 (1.01%) 1 Y
Taurodontism 1 (1.01%) 1 N
Supernumerary tooth 1 (1.01%) 1 N
Total 37 (37.37%) 33
Soft-tissue calcifications Calcification of the stylehyoid complex 18 (18.18%) 16 N
Tonsillolith 14 (14.14%) 14 N
Calcification of triticeous cartilage 7 (7.07%) 7 N
Greater horn thyroid calcification 2 (2.02%) 2 N
Total 41 (41.41%) 39
Others Residual root 4 (4.04%) 3 Y
Increased pericoronal space 1 (1.01%) 1 F
Total 5 (5.05%) 4
F, need follow-up; N, do not require treatment/referral; Y, need treatment/referral to another professional.
a
Many findings were classified as being asymptomatic. Treatment may be changed according to the symptoms and complaints of patients.
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The frequency of the IFs depends on the sample, age
group, criteria and categories of IFs that are considered
by each researcher. In this study, a high frequency of
IFs was obtained, i.e. findings not related to the purpose
of the examination, similar to results found in the lit-
erature (Table 6).
1,1012
A total of 560 IFs were found in 138 of the 150 exami-
nations. Therefore, 92% of the examinations showed at
least one IF and 8% examinations did not present any
findings. The average number of IFs per examination was
3.73. We observed that the maxilla/mandible group (n5
236) had a higher number of IFs than the maxilla group (n
5225) and the mandible group (n599) (Table 2). This can
be explained by the fact that the maxilla/mandible group
has FOV of the largest size (13 cm), thereby providing more
visible structures and a greater likelihood of IFs. The
maxilla group showed the greatest number of findings in
relation to the mandible, and this can be attributed to the
absence of airway zone and TMJ in the mandible group.
Airway findings
In this study, the airway was the zone with the second
highest number of findings and represented 24.46% of
the IFs (n5137). In the literature, there is a high fre-
quency of IFs in the airways, commonly the zone with
the first or second highest incidence of findings in re-
search (Table 6). In previous studies, frequencies of
findings in the airways of 35, 51.8, 18.8 and 73.2, re-
spectively, were reported.
1,8,11,12
The most frequent finding in this area was the
thickening of the maxillary sinus mucosa (n570)
(Figure 1), similar to studies in the literature.
1,11,15
In
a previous study, the majority of cases of sinusitis pre-
sented thickenings of the sinus mucosa bigger than
2 mm, so this value can be considered an important
indicator of maxillary sinusitis.
16
The large number and variety of findings in the air-
ways zone in this study shows how important it is for
dentists (Figure 1), especially radiologists, to understand
Table 5 Descriptive analysis and frequency of incidental findings (IFs) of CBCT examinations with the field of view encompassing the maxilla/
mandible
Zone IFs Number (%) of IF Number of patients with IF Clinical management
a
Airway Thickening maxillary sinus mucosa 29 (12.28%) 20 .2 mm: Y
Alveolar extension of the maxillary sinus 5 (2.11%) 5 N
Cyst retention/pseudocyst/polyp 4 (1.69%) 4 N
Turbinate hypertrophy 3 (1.27%) 3 Y
Deviated septum 2 (0.84%) 2 Y
Antrolith 1 (0.42%) 1 N
Total opacification of the maxillary sinus 1 (0.42%) 1 Y
Concha bullosa 1 (0.42%) 1 N
Total 46 (19.49%) 37
TMJ Flattening condyle 22 (9.32%) 15 F
Osteophytes 20 (8.47%) 16 F
Bifid condyle 1 (0.43%) 1 N
Total 43 (18.22%) 32
Bone Bone sclerosis 10 (4.23%) 10 N
Palatal torus 5 (2.11%) 5 N
Mandibular torus 1 (0.43%) 1 N
Exostosis 1 (0.43%) 1 N
Total 17 (7.20%) 17
Lesions of the jaw Periapical cyst 2 (0.84%) 2 Y
Bone dysplasia 1 (0.43%) 1 F
Total 3 (1.27%) 3
Teeth Impacted tooth 40 (16.94%) 16 F
Root dilaceration 13 (5.50%) 9 N
Giroversion 11 (4.66%) 6 N
Apical lesion 8 (3.38%) 6 Y
Supernumerary tooth 4 (1.69%) 2 F
Endoperio lesion 3 (1.27%) 3 Y
Agenesis 2 (0.89%) 1 N
Dens in dente 1 (0.42%) 1 Y
Enamel pearl 1 (0.42%) 1 N
External resorption 1 (0.42%) 1 Y
Total 84 (35.59%) 46
Soft-tissue calcifications Calcification of the stylehyoid complex 31 (13.13%) 17 N
Calcification of triticeous cartilage 5 (2.11%) 5 N
Tonsillolith 2 (0.89%) 2 N
Atheroma 2 (0.89%) 2 Y
Total 40 (35.59%) 26
Others Residual root 2 (0.89%) 2 Y
Increased pericoronal space 1 (0.42%) 1 F
Total 3 (1.27%) 3
F, need follow-up; N, do not require treatment/referral; TMJ, temporomandibular joint; Y, need treatment/referral to another professional.
a
Many findings were classified as being asymptomatic. Treatment may be changed according to the symptoms and complaints of patients.
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the nature of sinus changes. According to a systematic
review of the use of CBCT in airways, there has been
a significant increase in the number of publications on
this subject in the past 5 years and the results indicate
that CBCT can be used to accurately and reliably assess
the airways.
17
Temporomandibular joint findings
The TMJ was the fourth most frequent zone of IFs in
this sample (n592) with a frequency of 16.42%
(Figure 2), which is similar to previous studies with
a frequency of 15.4
1
and 11.1%
2
and less than that in
another study, with a frequency 39.31%.
15
44 cases of flattening condyle and 47 cases of osteo-
phytes were observed in this study (Figure 3). Flattening
is represented by the loss of convexity of the condyle
and is a signal of a remodelling bone or a physiological
response to the increase of load in the region. An
osteophyte is a marginal excrescence on the surface of
the condyle that appears in the later stage of de-
generative changes in the TMJ, when the body is
adapting to repair the joint (Figure 3).
18
Degenerative
diseases of the TMJ detected on CBCT can be an IF,
and patient history, clinical findings and symptoms are
important in determining disease activity. Patients with
symptoms such as pain and limited mouth opening need
referral or intervention, while those without such
symptoms do not need treatment, only monitoring.
1
One case of unilateral bifid condyle (Figure 3), in
a 23-year-old patient, was also found. A bifid condyle is
a rare anomaly and may be unilateral or bilateral and
anteroposterior or mediolateral. Although the aetiology
Table 6 Previous studies of prevalence of incidental findings (IFs) in CBCT examinations
Study CBCT scanner
Mean age
(range) (years) FOV
Number of examinations
with IF (%)
Number of IF
a
Zone with the highest
number of findings
Price et al 2011
1
NewTom 3G
Sirona Galileos 3D
Comfort
49.3 (980) 6 or 9 cm 272 examinations
(90.7%)
881 findings
Airway
Pette et al 2012
15
i-CAT Males 64.7; females
62.4 (1691)
13 cm 789 findings Paranasal sinuses
Allareddy
et al 2012
10
i-CAT 587 (not reported) 13 cm 943
examinations (94.3%)
Teeth
Ça˘
glayan;
Tozo˘
glu 2012
11
NewTom 3G 30.3 (974) Not reported 192
examinations (92.8%)
Airway
Drage et al 2013
9
i-CAT Classic
®
(Imaging
Science International,
Hatfield, PA)
14.5 (not reported) 4 cm 66% examinations
370 findings
Teeth
Edwards
et al 2014
12
i-CAT Next Generation 6.3 (546) Large: size not
reported
356 examinations
(83.4%)
842 findings
Airway
Rheem
et al 2013
13
Hitachi CB MercuRay
Care stream 9300
Mean age not
reported (880)
Not reported 59
examinations (40.1%)
Paranasal sinuses
Present study i-CAT Classic 37 (891) 6-cm: maxilla
6-cm: mandible
13-cm: maxilla and
mandible
138 examinations (92%)
560 findings
Teeth
FOV, field of view.
a
Some authors describe their results only with the total number of examinations with IFs or with only the total number of IFs; NewTom 3G
(Quantitative Radiology, Verona, Italy); Sirona Galileos 3D Comfort (Sirona Dental Systems, Charlotte, NC); i-CAT (Imaging Sciences,
Hatfield, Pennsylvania, PA); i-CAT Classic
®
(Imaging Sciences, Hatfield, Pennsylvania, PA); i-CAT Next Generation (Imaging Sciences,
Hatfield, Pennsylvania, PA); Hitachi CB MercuRay (Hitachi Medical Corporation, Tokyo, Japan); Care stream 9300 (Carestream Health Inc,
Rochester, NY).
Figure 1 An antrolith (arrow) associated with mucosal thickening of the right maxillary sinus and mucosal thickening of the left maxillary sinus in
coronal reformatting (a); the arrow is indicating mucosal thickening of the sphenoid sinus in the axial reformatting (b); nasal septum deviation, alveolar
extension of the maxillary sinus bilateral and bucosinusal communication in the left maxillary sinus in coronal reformatting are indicated by the arrow (c).
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is not fully understood, evidence suggests development
change or traumatic aetiology. No treatment was in-
dicated for that patient.
1
Bone findings
This zone corresponds to 7.32% (n542) of the IFs in
this study and was the zone with the fifth highest in-
cidence of findings (Figure 2). In the literature, we ob-
served a greater number of findings in this zone with
a frequency of 1517%.
1,13
24 cases of bone sclerosis were observed in this study
(Figure 4). This condition is considered asymptomatic
and does not cause expansion of the cortical bone.
Bone sclerosis consists of hyperdense intraosseous
lesions that do not result from infection or systemic
disease and have an unknown aetiology. Ignorance of
the frequency and location of these images can result in
erroneous diagnosis suggestions. No treatment is re-
quired in cases of bone sclerosis.
1
14 cases of palatal torus (Figure 4), 1 case of man-
dibular torus and 1 exostosis were also found in this
study. Torus and exostosis are anatomical variations
characterized by hard bony prominences located on the
hard palate (palatal torus), the lingual plate of the
mandible (mandibular torus) or the buccal plate of the
maxilla and mandible (exostosis).
19
Because they are
asymptomatic, they usually do not require treatment,
but they may be removed for prosthetic reasons and for
use as biomaterials in periodontics and implantology.
1
Lesions of the jaw findings
We noted in this sample a low frequency of IFs in this
zone (1.96%) (Figure 2), similar to the results found in
the literature, with frequency ranging from 0.1 to
3.5%.
1,20
It is important to emphasize that the findings
were described only with tomographic characteristics
and there was no clinical and histopathological exami-
nation of these. Therefore, the diagnosis is suggestive
and not definitive.
One case of osteoma was found in this study at the
lower border of the mandible (Figure 5). Osteomas are
benign and asymptomatic tumours. However, they can
increase in size causing cosmetic disfigurement and
functional impairment and therefore require radio-
graphic follow-up. It is important to evaluate their
possible relationship with Gardners syndrome.
1,21
Two cases of odontomas were found in this study. An
odontoma is a tumour formed by the dental tissue that
presents itself as a calcified mass, with a rounded or
irregular shape.
22
The treatment consists of surgical
removal.
23
Six cases of periapical cyst (Figure 5) and one dentig-
erous cyst were found in this study. These cysts can cause
cortical expansion, root resorption and displacement of
adjacent teeth. None of the cysts observed were large and
the treatment normally recommended is enucleation. A
diagnosis of the dentigerous cyst was considered in this
study when the follicular space was .5mm and the peri-
apical cysts when the apical lesion was .10 mm.
23
We also found one case of bone dysplasia in a 54-
year-old female patient. This fibro-osseous lesion rarely
produces symptoms and requires no treatment. However,
regular monitoring with periodic radiographs is recom-
mended to evaluate the development of the injury.
1
Figure 2 Frequency of distribution of incidental findings by zone
evaluated in the total sample.
Figure 3 Coronal reformatting: flattening condyle (a); osteophytes (b); and bifid condyle (c).
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Tooth findings
The largest number of IFs in this research was found in
the tooth zone, with 27.32% of the findings (Figure 2),
similar to a previous study.
9
A total of 153 IFs were
observed, involving dental anomalies and pulp, peri-
apical and periodontal changes.
105 cases of dental anomalies were found. Teeth
with taurodontism, supernumerary roots and root
dilaceration do not require treatment. However, in
cases of endodontic treatment or surgery, such teeth
require better evaluation. Patients with agenesis re-
quire treatment only in cases of aesthetic or functional
disability. In teeth with giroversion, orthodontic
treatment may be indicated depending on their degree
of rotation.
23
A case of dens in dente of a maxillary central in-
cisor was found. The invagination often communi-
cates with the oral cavity, allowing the entry of
irritants and microorganisms directly into the
pulp tissues. In such cases, restorative treatment is
necessary, or in more severe cases, endodontic
treatment.
23
Cases of supernumerary teeth and impacted teeth
were also observed (Figure 6), and the treatment of
these teeth depends on their position and their effects on
the adjacent teeth. Diagnosis and early treatment are
important to minimize the risk of complications.
1
Furthermore, we also observed 48 cases of end-
odontic and periapical changes. Pulp calcifications
are asymptomatic and do not need treatment,
whereas apical lesions, endoperio lesions (Figure 6)
and furcation lesions require treatment by a
dentist.
23
Soft-tissue calcification findings
The soft-tissue calcification zone is the third most
prevalent finding in the sample, with 20.53% of the
findings (Figure 2), which is similar to a previous study
with 20%
1
and above the amount found by another
study
13
with 12.92%.
With regard to age, it was found as a statistically
significant difference that the older the patient, the
greater the number of calcifications. This corrobo-
rates with a systematic review of research of IFs, in
which the authors concluded that soft-tissue calcifi-
cations were much more common where there was
a sample with older people.
2
Patients in another
CBCT study demonstrated that atheroma was 13.4
times more common in patients older than 65 years.
In our study, 50% of the sample was patients more
than 40 years.
15
A diagnosis of ossification of the stylehyoid
complex was made in 82 cases (Figure 7), which
was considered in this study to be cases above 3-cm
long.
24,25
Usually, it shows no symptoms and no
treatment is necessary. However, if there are any
symptoms, they may be associated with Eagles
syndrome.
25
Figure 4 Palatal torus in coronal reformatting (a) and bone sclerosis in sagittal reformatting (b).
Figure 5 A periapical cyst in sagittal reformatting (a); arrow is indicating osteoma in the panoramic reformatting (b).
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17 cases of tonsilloliths were diagnosed in this study.
These calcifications are present in the tonsils and can
be single or multiple. They are usually asymptomatic
and no treatment is usually necessary. Larger ones can
cause bad breath, a sore throat, dysphagia or for-
eign body sensation, thereby requiring medical
treatment.
1,24
Two cases of atheroma were observed in this study
(Figure 7). Atheromas present as single or multiple rice
grains, with homogeneous density, and lateral cervical
vertebrae in positions ranging between C3 and C4.
2
Referral of these patients to a specialist to confirm the
diagnosis contributes significantly to reducing stroke
and its sequelae.
26
The calcification of the triticeous cartilage and
greater horn thyroid calcification was observed in
14 patients (Figure 7). Thyroid cartilage is part of the
skeleton of the upper larynx and triticeous cartilage is
located in the thyrohyoid ligament. They are bilateral
ovoid structures that have a tendency to calcify with
increasing age and are IFs without clinical symptoms.
No treatment is necessary.
1
Clinical management of incidental findings
In this study, most of the IFs do not require treatment or
referral to another professional. This shows that not all
IFs in CBCT examinations have a great impact on the
health of the patient and only a minority need medical or
dental work. In the literature, we observed similar results.
In a previous study, 43.46% of IFs did not require
treatment, 28.97% findings required monitoring and
a minority of findings, with 22.57%, needed treatment or
referral to another professional.
1
In another study, only
two results were significant enough to cause changes in
orthodontic treatment in the sample.
9
In another previous
study, only 1 IF of high importance was reported, with
the other 97 findings being of intermediate importance
and 242 findings of low importance.
20
We observed a large variety and quantity of IFs in this
sample, which shows the importance of a dentist/
radiologist evaluating the entire volume of the CBCT ex-
amination. In addition, the results reinforce the need for
dentists to study and recognize the entire anatomy and
anatomical variations of the maxillofacial region. In the
literature, there are some researches with the same
Figure 6 The arrows are indicating supernumerary teeth in sagittal reformatting (a); an endoperio lesion in the sagittal reformatting (b); and
a tooth retained causing external resorption in the adjacent tooth in the sagittal reformatting (c).
Figure 7 Ossification of the styloid complex (white arrows), calcification of the triticeous cartilage (long black arrow) and calcification of the
greater horn of the thyroid (short black arrow) in sagittal reformatting (a); the arrow is indicating atheroma in sagittal reformatting (b).
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approach, but none with a Brazilian sample. There is
a variation in the frequency and type of IFs between
different samples. For example, in a study that used an
Indian sample, the most frequent IFs were malignant
lesions.
14
Conclusions
A total of 560 IFs were found in 92% of the samples
studied, with the maxilla/mandible group presenting
more findings, followed by the maxilla and finally the
mandible group.
The most frequent zone of IFs was the teeth zone,
followed by airways, soft-tissue calcification, TMJ,
bone and lesions of the jaws.
Most of the IFs of this sample do not require
treatment or referral to another professional.
A statistically significant difference in the soft-tissue
calcification zone was found, where there were
a greater number of IFs with increasing age.
This study showed a high frequency of IFs in CBCT
examinations for dental purposes. The findings showed the
importance for dentists/radiologists to examine the entire
volume of the CBCT examination, in the three reforma-
tions, not only the purpose of the examination region.
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... This imposes requirements on the imaging and the diagnostic process with regard to: 1. radiation exposure of the patient, 2. evaluation of a possibly large and complex three-dimensional examination area, and 3. interpretation of pathologies beyond the professional focus of the clinical specialist, especially for incidental findings (IF) and their implications for further therapy. Lopes et al. [16] detected an average of 4.72 incidental findings in a total of 47 examinations that covered both the mandible and the maxilla. Nguyen et al. found an average of 1.85 IF per scan in 555 patients of an older population for pre-implant assessment [17]. ...
... Our mainly used FOV wit 100 × 100 mm 2 was rather small compared to the studies mentioned above. In some othe studies, a smaller FOV was chosen [16,26,27]. The non-homogenously distributed numbe of examinations with a specific FOV was certainly a limitation of our study. ...
... Our mainly used FOV with 100 × 100 mm 2 was rather small compared to the studies mentioned above. In some other studies, a smaller FOV was chosen [16,26,27]. The non-homogenously distributed number of examinations with a specific FOV was certainly a limitation of our study. ...
Article
Full-text available
Cone beam computed tomography (CBCT) is increasingly used for dental and maxillofacial imaging. The occurrence of incidental findings has been reported, but clinical implications of these findings remain unclear. The study’s aim was to identify the frequency and clinical impact of incidental findings in CBCT. A total of 374 consecutive CBCT examinations of a 3 year period were retrospectively evaluated for the presence, kind, and clinical relevance of incidental findings. In a subgroup of 54 patients, therapeutic consequences of CBCT incidental findings were queried from the referring physicians. A total of 974 incidental findings were detected, involving 78.6% of all CBCT, hence 2.6 incidental findings per CBCT. Of these, 38.6% were classified to require treatment, with an additional 25.2% requiring follow-up. Incidental findings included dental pathologies in 55.3%, pathologies of the paranasal sinuses and airways in 29.2%, osseous pathologies in 14.9% of all CBCT, and findings in the soft tissue or TMJ in few cases. Clinically relevant dental incidental findings were detected significantly more frequently in CBCT for implant planning compared to other indications (60.7% vs 43.2%, p < 0.01), and in CBCT with an FOV ≥ 100 mm compared to an FOV < 100 mm (54.7% vs 40.0%, p < 0.01). Similar results were obtained for paranasal incidental findings. In a subgroup analysis, 29 of 54 patients showed incidental findings which were previously unknown, and the findings changed therapeutical management in 19 patients (35%). The results of our study highlighted the importance of a meticulous analysis of the entire FOV of CBCT for incidental findings, which showed clinical relevance in more than one in three patients. Due to a high number of clinically relevant incidental findings especially in CBCT for implant planning, an FOV of 100 × 100 mm covering both the mandible and the maxilla was concluded to be recommendable for this indication.
... 2 Most of the CBCT scans retrieved were of a single quadrant (35% in the maxilla) with limited FOV justifying guidelines set by AAPD (ALARA principle). The result corroborates with the study by Lopes et al. 10 where CBCT scans of maxilla from the majority group. Most of the cases subjected for CBCT scans were for orthodontic purposes (36%) which included scans for localization of teeth/impacted teeth (17%) with the least scans for cleft lip and palate patients (2%). ...
... The mucosal thickening can lead to airway obstruction and the possible cause may be malocclusion, odontogenic infections, and disharmonious dentofacial development. 10 Mucosal thickening of >3 mm (Ruprecht and Larn) or 4 mm (Macdonalds) is considered pathologic. 9,14 Cone-beam computed tomographic scans can provide us details and help in assessing the sinus changes, thus can be considered as a standard tool in the screening of airway abnormalities. ...
... Supernumerary teeth were the major findings reported (2.8%), wherein mesiodens being the commonest type. The findings were similar to results by Lopes et al., Rai et al.,and Allareddy et al. 1,10,18 Among the 1.4% of congenitally missing teeth, premolar teeth were the predominant ones. The overall prevalence of congenitally missing teeth is reported to be 4% wherein mandibular pre-molars (excluding III molars) are found frequently missing. ...
... All five of the included studies were retrospective studies from a single center. They were published in English from 2011 to 2018 [36][37][38][39][40]. The sample sizes ranged from 150 to 500 scans, and the age range of participants was 8-91 years. ...
... The proportion of males ranged from 29.5 to 45.3%. Three articles were conducted in the USA [36,38,40], one from Brazil [39], and one from Australia [37]. The indications for CBCT imaging varied; 4 of the 5 articles were for dental implant treatment planning [36,[38][39][40]. ...
... Three articles were conducted in the USA [36,38,40], one from Brazil [39], and one from Australia [37]. The indications for CBCT imaging varied; 4 of the 5 articles were for dental implant treatment planning [36,[38][39][40]. One study analyzed scans taken for the investigation of impacted or ectopically erupting maxillary canine [37]. ...
Article
Objective This systematic review was conducted to assess the types, potential clinical significance, and treatment implications of incidental findings (IFs) in CBCT diagnostic imaging of the maxillofacial region.Material and methodsThe authors searched several electronic databases and grey literature without time restriction for studies on the IFs in maxillofacial CBCT. Studies that classified the IFs based on their potential clinical significance were included. The methodological quality of the included studies was evaluated by the STROBE criteria.ResultsThe online searches of the electronic databases yielded 1323 records. Five articles were included in the final qualitative analysis. The methodological quality ranged from low to moderate risk of bias. Percentages of IFs with high (requiring intervention/referral), moderate (requiring monitoring), and low clinical significance ranged from 0.3 to 31.4%, 15.6 to 28.9%, and 43.46 to 71.1%, respectively. There was an inconsistency between the studies in the clinical significance of 58.8% of the IFs identified.Conclusion Most IFs in maxillofacial CBCT are either normal variants or findings that do not require referral or treatment. There was no clear consensus on the recommended management of most common IFs. The lack of consensus on clinical significance emphasizes the importance of collaboration between medical and dental specialties to establish professional guidelines for the management of commonly encountered IFs in CBCT.
... Only 18.8% of samples had airway problems in their study, while most of the other studies suggested that they had detected incidental findings of airways in 50% of samples. Lopes et al. 28 found a similar prevalence rate (18.7%) of incidental findings in airways, but the total prevalence rate (92%) was much higher. The differences came from other abnormalities such as temporomandibular joint (TMJ) lesions, soft tissue calcification, and pathological problems. ...
Article
Full-text available
Some craniofacial diseases or anatomical variations are found in radiographic images taken for other purposes. These incidental findings (IFs) can be detected in orthodontic patients, as various radiographs are required for orthodontic diagnosis. The radiographic data of 1020-orthodontic patients were interpreted to evaluate the rates of IFs in three-dimensional (3D) cone-beam-computed tomography (CBCT) with a large field of view (FOV) and investigate the effectiveness and accuracy of two-dimensional (2D) radiographs for detecting IFs compared to CBCT. Prevalence and accuracy in five areas was measured for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The accuracies of various 2D-radiograph were compared through a proportion test. A total of 709-cases (69.5%) of 1020-subjects showed one or more IFs in CBCT images. Nasal cavity was the most affected area. Based on the CBCT images as a gold standard, different accuracies of various 2D-radiographs were observed in each area of the findings. The highest accuracy was confirmed in soft tissue calcifications with comprehensive radiographs. For detecting nasal septum deviations, postero-anterior cephalograms were the most accurate 2D radiograph. In cases the IFs were not determined because of its ambiguity in 2D radiographs, considering them as an absence of findings increased the accuracy.
... CBCT scans are widely utilized for various purposes, including evaluations of the airway, dental and jaw trauma, infections, temporomandibular joint pathologies, endodontic lesions, impacted teeth, developmental and congenital jaw deformities, and oral and maxillofacial pathology. 1,3,7 In recent years, with advances of technology in 3-dimensional printing and the introduction of the surgical guide implant planning, increasingly many private offices utilize CBCT machines, although the actual number of CBCT scan users in the United States is not known. The increase in the use of CBCT scans underscores the importance of a proper diagnostic evaluation of the entire CBCT volume. ...
Article
Full-text available
The increased use of cone-beam computed tomographic (CBCT) scans has made it increasingly necessary to evaluate incidental findings on CBCT scans. This report describes the case of a 66-year-old female patient who presented to the Department of Oral and Maxillofacial Pathology, Radiology and Medicine at the College of Dentistry of the author's institution and underwent a CBCT scan for maxillary alveolar process implant planning. Upon evaluation of the CBCT scan, a radiopaque (soft tissue attenuation) mass in the left superior aspect of the nasal cavity and left locule of the sphenoid sinus with opacification of the left locule of the sphenoid sinus was incidentally noted. These radiographic findings were suggestive of a space-occupying mass with a high possibility of malignancy. A further medical evaluation confirmed renal cell cancer metastasis to the sphenoid sinus. This study shows the significance of reviewing the entire CBCT scan for incidental findings.
... 3 The IADMFR report recommended that, where possible, at least one instructor in oral radiology should be a Board/College certified DMF radiologist. 33 Furthermore, with a 24.6-93.4% 36 likelihood of an incidental finding in a CBCT scan, and one in three of these findings requiring follow-up or referral, 37 there is significant benefit to both the patient and practitioner in working with an appropriately trained radiologist for the interpretation of CBCT scans, 19,31,35 particularly large volume CBCT scans. As the referring dentist is responsible for the entire scan volume and is held to the same standard as a specialist, 26,38 the perils of self-reporting and the potential resulting medico-legal consequences 19,35,36 are evident. ...
Article
Full-text available
Objectives This is a follow-up study to assess growth in the number of cone beam computed tomography (CBCT) and panoramic radiography (PR) machines in Australia. It is also the first study to evaluate the current status of both CBCT and PR education in Australia. Methods CBCT and PR machine numbers were obtained from the radiation regulators across Australia. Australian dental schools were surveyed via email. The number of machines relative to population size and the number of dentists were calculated. Results In 2020, there were 706 CBCT machines and 3,059 PR machines, representing a 204.3% increase in the number of CBCT machines and an 82.0% increase in the number of PR machines over six years. Majority of Australian dental schools owned PR and CBCT machines. Most taught PR acquisition and interpretation, however only one-third taught CBCT image acquisition and interpretation to predoctoral students. Conclusions CBCT machine numbers increased by nearly three-fold while PR machines only increased by 1.6 times over a six-year period relative to population size and number of dentists. Only very few Australian dental schools provide CBCT education to predoctoral students, raising concern as to whether graduates are adequately trained upon program completion.
... Sua correta identificação é fundamental para que não ocorram sugestões errôneas de diagnóstico, visto que nenhum tratamento é necessário. 26 A análise dos resultados desta pesquisa evidencia a importância de uma avaliação minuciosa das radiografias panorâmicas realizadas em crianças, realizada além da área de indicação do exame, dada a possibilidade de identificar alterações clinicamente relevantes, beneficiando o paciente infantil. ...
Article
Objective We aimed to present the radiologic characteristics of maxillofacial soft tissue calcifications with a comparison of cone beam computed tomography (CBCT) and panoramic radiography (PR) findings. Materials and Methods The study was based on CBCT images obtained for different purposes between October 2017 and September 2018. The absence, location and radiological characteristics of some calcifications were evaluated in 252 patients. Statistical analysis was performed with SPSS version 21.0; p < 0.05 was considered to indicate statistical significance. Results Palatine tonsilloliths were the most common calcifications in our study. Calcifications were most frequent in the sixth decade of life. Females had larger calcifications than males. There was a relationship between the sizes measured by CBCT and PR for tonsilloliths. In PR, region 2 had significantly more calcifications compared with the other regions. The C2 vertebral level was the most common region for tonsilloliths based on CBCT. Conclusions Tonsilloliths have a high prevalence. The regular peripheral type had a higher risk of being a tonsillolith in PR. The peripheral/internal characteristics and the dimensions of calcifications between the two imaging modalities were in harmony. The location of calcification in PR and CBCT was important to distinguish the type of calcification.
Article
Aim To evaluate the presence of bacteria in permanent teeth with intact crowns (without caries, periodontal disease, or dental trauma) in sickle cell anaemia patients (HbSS genotype) by analyzing their clinical, imaging, and microbiological parameters. Methodology This is a case series study nested in a cohort. In the first follow‐up of this cohort study (Costa et al. 2013), ten HbSS patients with at least one tooth with intact crown and clinically diagnosed with pulp necrosis, by pulse oximetry adapted for dentistry and a cold sensitivity test (n = 27 teeth), were selected. Changes in the pulp chamber, root, and periodontal ligament were identified in the tomographic analysis. Bacterial culture, staining for live and dead bacteria, and real‐time polymerase chain reaction with 16S rRNA primers were used to identify the presence of bacteria. Culture sample collection was performed immediately after access to the pulp chamber. The microbiome was analyzed with a MiSeq sequencer (Illumina, San Diego, CA). Results The diagnosis of pulp necrosis was clinically confirmed in 82% (22/27) of the teeth. The amount of bacterial load identified was less than 100 copies/μL in 23% (5/22) of the teeth with intact crowns and pulp necrosis. Thirteen bacterial species were identified that are commonly found in urinary tract infection, septicemia, and infective endocarditis. Only one of these species, Granulicatella adjacens, has also be found in primary endodontic infections. Conclusion Prospective clinical, imaging and microbiological analyses suggest that pulp necrosis of teeth with intact crowns from HbSS patients is not caused by the presence of bacteria.
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Some craniofacial diseases or anatomical variations are found in radiographic images taken for other purposes. These incidental findings(IFs) can be detected in orthodontic patients, as various radiographs are required for orthodontic diagnosis. To evaluate the rates of IFs in three-dimensional(3D) cone-beam-computed tomography (CBCT) with a large field of view (FOV) and investigate the effectiveness or accuracy of two-dimensional (2D) radiographs for detecting IFs compared to CBCT, the radiographic data of 1,020-orthodontic patients were interpreted. Prevalence in five areas was measured, and sensitivity, specificity, positive predictive value (PPV), negative predictive value(NPV), and accuracy were calculated. The accuracies of various 2D-radiograph were compared through a proportion test. A total of 709-cases(69.5%) of 1,020-subjects showed one or more IFs in CBCT images. Nasal cavity was the most affected area. Based on the CBCT images as a gold standard, different accuracies of various 2D-radiographs were observed in each area of the findings. The highest accuracy was confirmed in soft tissue calcifications with comprehensive radiographs. For detecting nasal septum deviations, postero anterior cephalograms were the most accurate radiograph. A possible improvement in accuracy for detecting IFs is expected by the development of CBCT with a lower radiation dose and higher resolution.
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Cone beam computed tomography is a new diagnostic innovation to dental imaging. Despite the use of CBCT in oral and maxillofacial imaging, reports on its use either by individual practitioners or referral patterns to CBCT centers is lacking. Hence, a study was conducted to determine incidental findings on CBCT and reasons for referral by dental practitioners in Indore city. A retrospective analysis of 795 records that were referred for CBCT imaging at Institutional and Oracal CBCT Centre, Indore was undertaken. Referrals from both within and outside institution, as well as from private practitioners were considered. The reason for CBCT referral, provision diagnosis, final diagnosis and any incidental diagnosis were recorded. This retrospective chart audit revealed that 56.7 % were male and 43.3% were females. Greatest source of patients was referred by oral surgeons (21.9%) followed by oral and maxillofacial radiologist (14.2%) and prosthodontist (9.3%). The most common reason for referral was for implant analysis (24.2%) and the most common incidental finding diagnosed by CBCT was oral malignancies. In Institutional set-up, CBCT referrals were mostly for the reason of planning implant placement followed by trauma whereas private practitioners used CBCT mostly for implant placement followed by impaction. CBCT was being utilized more by Oral surgeons in private sector whereas it in an Institutional setup majority of referrals from Department of Oral Diagnosis and Radiology. Findings that were most commonly diagnosed incidentally on CBCT were Orofacial malignancies followed maxillary sinus pathologies.
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Background: The aim of this study is to evaluate the nature and frequency of incidental findings in large-field maxillofacial cone beam computed tomography (CBCT). Methods: A total of 427 consecutive CBCT radiologic reports obtained for orthodontic purposes were retrospectively reviewed. Findings were summarized and categorized into six anatomic categories. Results: A total of 842 incidental findings were reported in the 427 CBCT scans (1.97 findings/scan). The most prevalent findings were those located in the airway (42.3%), followed by the paranasal sinuses (30.9%), dentoalveolar (14.7%), surrounding hard/soft tissues (4.0%), temporomandibular joint (TMJ) (6.4%), and cervical vertebrae (1.3%) regions. Non-odontogenic findings, defined as those located outside the dentition and associated alveolus, represented 718 of the 842 (85.3%) findings. Conclusions: This study confirms the high occurrence of incidental findings in large-field maxillofacial CBCT scans in a sample of orthodontically referred cases. The majority are extragnathic findings, which can be normally considered outside the regions of interest of many dental clinicians. Specifically, incidental findings in the naso-oropharyngeal and paranasal air sinuses are the most frequent. This underscores the need for comprehensive review of the entire data volume and the requisite to properly document all findings, regardless of the region of interest.
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The stylohyoid process is a cylindrical bony structure surrounded by important anatomical structures including vessels and nerves. Calcification and elongation of the stylohyoid ligament complex over 30 mm may be associated with neck and facial pain, known as Eagle's syndrome. However, a bilateral ossified and elongated stylohyoid complex may be devoid of symptoms. We report a 79-year-old symptom-free female who presented on a routine conventional dental radiographic exam an 80.96 mm psendoarticulated stylohyoid complex in the left side and an 75.85 mm on the other. On CAT scan, both processes were calcified.
Article
Background: Cone beam computed tomography (CBCT) is a three-dimensional radiographic imaging technique that is commonly being used in diagnosis and treatment planning in various fields of dentistry. Incidental findings on CBCT images are frequently reported in the literature and are important to assess before treatment planning. Aims: To record types and prevalence of incidental findings in the maxillofacial region, identified on CBCT scans and described in radiologist's consultation reports. Settings and Design: A total of 147 CBCT scan reports on 59 males and 88 females between June 2007 and February 2012 at University of California, San Francisco, were analyzed retrospectively. Methods and Material: 147 patient reports by Board certified oral radiologists on CBCT scans taken with the Hitachi CB MercuRay. The incidental findings were categorized and analysed using descriptive statistics. Statistical Analysis Used: Logistic regression analysis was used to compare the rate of temporomandibular joint (TMJ) pathologies between females and males. Results: The overall rate of incidental findings was 40.1%. The age range of patients was from 8 years to 80 years. The highest rate of incidental findings was in the sinus region (51.7%), followed by dento-alveolar region (34.01%), TMJ region (26.53%), osseous region (15.64%), calcification of ligaments, pineal gland, and carotid artery (12.92%), dental anomalies (10.88%), nasal region (8.84%), and airway region (5.44%). According to logistic regression analysis, females were 2.58 times more likely to exhibit TMJ pathology compared to males ( P value = 0.02). Conclusions: CBCT scans are beneficial in revealing incidental abnormalities in the head and neck region outside the scope of interest. Careful review of the entire CBCT image is essential to avoid under- or overestimation of potential complications in providing comprehensive health care.
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Apart from a few exceptions, dental practitioners are not familiar with sectional images (as those provided by cone beam computed tomography [CBCT]). In addition, the maxillofacial region is a complex area from an anatomic point of view including structures of peculiar shape; this may add to that complexity of their appearance in CBCT. As a result, a thorough knowledge of the tomographic anatomy of the maxillofacial region was necessary. This chapter reviews pertinent anatomical structures of the maxillofacial region in the axial, coronal, sagittal planes, as well as custom planes. Related pathology is also shown and discussed.
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Despite the nomenclature suggested to be a tumor, torus palatinus (TP) is an overgrowth of the bone in the palatal region and represents an anatomic variation. Its prevalence varies among the population studied and its etiology is still unclear; however, it seems to be a multifactorial disorder with genetics and environmental involvement. Surgical removal of the TP is indicated in the following circumstances: (1) deglutition and speech impairment, (2) cancer phobia, (3) traumatized mucosa over the torus, and (4) prosthetic reasons. The aim of this case report is describe cases that occurred in two sisters, emphasizing the genetic etiology of this anatomic variation. In addition, intra-oral exam and computed tomography scan (axial, coronal and sagittal view) provided a detailed assessment of the TP and elimination of other possible diagnoses, furthermore allowed a better analyzes of the anatomic relation with adjacentes structures. No surgical removal was indicated for both cases.
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Osteoma is a benign osteogenic neoplasm microscopically consisting of proliferation of cancellous or compact bone. Peripheral osteomas (PO) arise from the periosteum and are quite uncommon in the jaw bones. POs of mandible are considered as rare entity and very few cases have been reported in the literature. The pathogenesis of PO is unclear. Some investigators consider it a true neoplasm, while others believe it as a developmental anomaly, a reactive mechanism due to trauma or infection. The purpose of this article is to present the clinical, radiographic, surgical and histological features of a solitary peripheral osteoma of the mandible in a 43-year-old woman and to review the literature for PO located in the mandible.
Article
Objectives: The objective of this study was to find out the incidence of incidental findings seen in cone beam computed tomography scans taken for orthodontic purposes and to see if these findings influence orthodontic treatment. Subjects and method: Three hundred and twenty-nine consecutive scans carried out for orthodontic purposes using an i-CAT Classic were included in the study. Each scan was evaluated by a single radiologist and any incidental findings recorded. The incidental findings were further classified depending on whether the finding would influence orthodontic management. Results: There were a total of 370 incidental findings in the 329 scans, with at least one incidental finding in 66% of patients. The most common incidental findings were dental (n = 120) and included retained deciduous roots (n = 24) and periapical disease (n = 15). Of the incidental findings 200 required no follow-up. A total of 168 findings required follow-up, but the overall orthodontic treatment plan was not altered. Only two findings were significant in that the orthodontic treatment was amended in light of the incidental finding. Conclusions: Incidental findings are very common on CBCT. However the majority of these findings do not affect orthodontic treatment planning.