Prof. Ingrid Różyło-Kalinowska
MD, PhD, DSc
• Prof. Ingrid Różyło-Kalinowska, is Head of the Department of Dental and Maxillofacial Radiodiagnostics at the Medical University of Lublin, Poland.
• A specialist in radiology and diagnostic imaging, she has published extensively, authored and co-edited leading textbooks on CBCT and digital workflows, and serves as Editor-in-Chief of the Journal of Stomatology.
• Past President of the European Academy of DentoMaxillofacial Radiology, she is a frequent invited speaker at international congresses, with particular expertise in cone beam computed tomography and its role in safe, precise digital dentistry.
• Her contribution to the upcoming joint events in Venice — the DDS Congress and the IADMFR meeting — underscores the importance of radiological reporting as the foundation of effective digital dentistry planning.
Introduction
Introduction
Digital dentistry relies on accurate imaging as the foundation for every procedure, whether straightforward or complex. Traditionally, 2D radiographs guided clinical decision-making, but the advent of cone beam computed tomography (CBCT) has transformed diagnostic capability, offering a comprehensive 3D view of dental and maxillofacial structures. However, advanced imaging is only as valuable as its interpretation. Specialist radiologists play a crucial role in providing detailed, systematic reporting, ensuring that treatment plans are both appropriate and safe. This case highlights the importance of CBCT and expert radiological input in optimizing digital dentistry workflows and safeguarding patient outcomes.
case report
case report
A 65-year-old male patient with a non-remarkable medical history was referred by his dentist for a CBCT scan before planning dental implant placement.
The patient was completely edentulous in the upper jaw, while only three teeth were preserved in the mandible, which served as a support for a fixed denture. Although the indications for the CBCT scan included only dental implant treatment, a large field of view (FOV)—16 × 17 cm—was obtained using Carestream Dental’s CS 9600 CBCT scanner. Consequently, the whole volume had to be carefully examined and reported.
The initial evaluation of the reconstructed panoramic view (Fig. 1) confirmed that there were no teeth in the maxilla, and only teeth numbers 43, 42, and 33 were preserved in the anterior mandible. All three teeth were treated endodontically, and root canal overfilling was observed in the canines. No periapical lesions were noted. The teeth served as support for a fixed prosthetic appliance.
“The advent of CBCT has transformed diagnostic capability, offering a comprehensive 3D view of dental and maxillofacial structures.”
The analysis of the curvilinear and cross-sectional views in thinner sections (Figs. 2 and 3) allowed for evaluation of the alveolar bone as potential support for dental implants. In the maxilla, the alveolar bone was atrophic, and the height of the residual alveolar ridge was very low, so it could not provide sufficient anchorage for dental implants.
The planning of dental implants was possible only in the posterior mandible. However, qualitative evaluation of the mandibular bone showed some rarefaction, which could compromise the primary stability of the implants (Fig. 2).
The report of the case seemed quite straightforward; however, greater attention had to be paid to all other structures visible in this large FOV.
Further evaluation of the scanned volume revealed several incidental findings that did not influence the dental implant treatment, but had to be included in the report, and potentially required further diagnostic imaging or follow-up.
The size of the incisive foramen was larger than usual (Fig. 4), which may be indicative of an incisive foramen cyst that, in symptomatic patients, and with further progression, would require surgical treatment.
Some streaks in the right compartment of the sphenoid sinus, suggesting thick mucus, were noted (Fig. 5).
Next, the bony structures of the cervical spine were evaluated. The CBCT images were consistent with osteoarthrosis, which presented as a narrowing of the joint space between the anterior arch of the C1 vertebra and the dens of the C2 vertebra, along with subchondral sclerosis and small osteophytes (Fig. 6). The height of the C3-C4 joint space was also reduced.
“Further analysis focused on soft tissue calcifications. Calcified atheromatic plaques were revealed in different locations.”
Afterwards, a well-defined bony outgrowth was noted in the anterior ethmoid cells on the left side (Fig. 7). The CBCT image suggested an osteoma, which is a benign tumor composed of mature bone cells, often located in paranasal sinuses. Although benign, the lesion is characterized by growth potential and may require surgery when larger and compromising sinus drainage.
Further analysis focused on soft tissue calcifications. Calcified atheromatic plaques were revealed in different locations along the course of carotid arteries, both in the neck (Fig. 8) and the intracranial sections of the internal carotids (Fig. 9). A calcified atheromatous plaque in the carotid arteries is a significant finding that suggests advanced atherosclerosis, which can increase the risk of stroke; however, the exact risk depends on several factors. If not discovered early, carotid artery calcifications may require further diagnostic workup, such as Doppler ultrasound examination of the carotid arteries or computed tomography angiography.
Conclusion
Conclusion
This case demonstrates the importance of the choice of the FOV in the CBCT scan, which is a critical factor in optimizing radiological protection. By selecting the smallest FOV necessary for the diagnostic task, unnecessary exposure to adjacent anatomical structures can be minimized, thereby reducing the patient’s overall radiation dose. This approach aligns with the as low as reasonably achievable (ALARA) principle, promoting patient safety without compromising diagnostic quality. Appropriate FOV selection also helps limit scatter radiation and improves image quality within the region of interest. The guidelines of numerous scientific associations highlight that the smallest possible FOV should be chosen in relation to specific indications.
“The case demonstrates the importance of the choice of the FOV in CBCT which is a critical factor in optimizing radiological protection.”
However, sometimes clinical practices are not in line with the guidelines, and clinicians select larger FOVs. Then, it is the practitioner who should take responsibility for reporting the whole scanned volume, as some incidental findings may have medical consequences. Depending on local laws and regulations in different countries, large FOV in CBCT scans can only be reported by medical radiologists; however, the regulations are less strict in many countries, and dentists can acquire and report CBCT scans regardless of the size of the FOV. Notably, dental curricula, both pre- and post-graduate, may not include information on radiological evaluation of structures located outside the maxilla and mandible. Therefore, the dental practitioners do not obtain sufficient training to be able to evaluate large FOVs comprising the head and neck. According to the famous 19th-century quotation, attributed to either Henry Bergson or Robertson Davies, “the eye sees what the mind is prepared to comprehend.” This powerful quote is unquestionably true in radiology and means that perception of an image is not just about vision—it is about training, experience, and expectation.
This case illustrates how CBCT scans with large FOV can reveal clinically significant findings beyond the immediate scope of the proposed treatment planning. While some of these findings require further clinical testing and diagnostic imaging to further assess risks to the patient’s general health, their identification highlights the need for thorough evaluation and specialist reporting.
In this era of digital dentistry, where precision and patient safety are paramount, a comprehensive interpretation of CBCT scan volumes is crucial to ensure that digital workflows are built on a foundation of accurate, responsible diagnostics.
REFERENCE
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812223/#:~:text=Oehler’s%20Type%20 III%20Dens%20Invaginatus%20as%20reported%20in%20this%20case,foramen%20 %5B1%2C%208%5D.
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