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This review analyzed the literature focused on Cone-Beam Computed Tomography (CBCT) diagnostic accuracy and efficacy in detecting impacted maxillary canines, and evaluated the possible advantages in using CBCT technique compared with traditional radiographs. PubMed and Embase searches were performed selecting papers since 1998 up to September 2011, moreover reference lists were hand searched. Two reviewers selected relevant publications on the basis of predetermined inclusion criteria. The literature search yielded 94 titles, of which 5 were included in the review. Three studies used CBCT technique to 3D localize maxillary impacted canines and assess root resorption of adjacent teeth. Other two publications compared traditional radiographs with CBCT images in the diagnosis of maxillary impacted canines. Only three studies presented the results using statistical analysis. The present review highlighted that the use of CBCT has a potential diagnostic effect and may influence the outcome of treatment when compared with traditional panoramic radiography for the assessment of impacted maxillary canines. Furthermore it underlines the need of future studies performed according with high level methodological standards, investigating diagnostic accuracy and effectiveness of CBCT in the diagnosis of maxillary impacted teeth.
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                                                                                                     Review article


    Localization of impacted maxillary canines using cone
    beam computed tomography. Review of the literature




                                                                                                 li
    Giulia Rossini, DDS, PhD Student                        Introduction




                                                                                              na
    Costanza Cavallini, MD
    Michele Cassetta, DDS, PhD                              Maxillary canines have the highest frequency of
    Gabriella Galluccio, DDS                                impacted localization after the third molars, with a
    Ersilia Barbato, DDS, MS                                prevalence ranging from 1% to 3% (1-4), and with
                                                            a 2:1 female to male ratio (5). Impacted maxillary




                                                                                           io
                                                            canines lead to aesthetic and functional drawbacks:
    “Sapienza” University of Rome, Italy                    alteration in the aesthetic of the smile, resorption of
    Department of Oral Sciences                             lateral incisors, cystic degeneration (5). Moreover, their




                                                                      az
                                                            surgical and orthodontic management is not easy and
                                                            time consuming to treat. Consequently, the accurate
    Corresponding Author:                                   localization of impacted maxillary canines is essential,
    Dr.ssa Giulia Rossini                                   especially if surgical intervention is required.




                                                                    rn
    Via Pasubio 15                                          In the daily practice the first radiographic image that
    00195, Rome, Italy                                      is required to support the clinical examination is the
    Tel/Fax +39.063223523                                   panoramic radiography. The localization of impacted teeth




                                                            te
    E-mail: giulia.rossini@uniroma1.it                      can be improved radiographically using a combination
                                                            of other bi-dimensional images: occlusal and periapical,
                                                            which allow the localization of impacted canines,
                                                            treatment planning, and evaluation of the treatment
    Summary
                                                    In      result. However the diagnostic accuracy of these bi-
                                                            dimensional radiographic techniques presents many
    This review analyzed the literature focused on Cone-    limitations such as distortion projection errors, blurred
    Beam Computed Tomography (CBCT) diagnostic              images and overlapping of structures, thus increasing
                                           ni
    accuracy and efficacy in detecting impacted             the risk of the lack of some important information. In the
    maxillary canines, and evaluated the possible           modern practice the localization of impacted maxillary
    advantages in using CBCT technique compared             canines and the assessment of lateral root resorption
                                   io


    with traditional radiographs. PubMed and Embase         can be drastically improved using information obtained
    searches were performed selecting papers since          from 3D investigations. Several previous studies used
    1998 up to September 2011, moreover reference           Computed Tomography (CT) (6-9). However, the high
                           iz



    lists were hand searched. Two reviewers selected        effective dose and the relatively high costs limit the
    relevant publications on the basis of predetermined     use of this technique in the daily practice. With the
    inclusion criteria. The literature search yielded       introduction of low dose volumetric CT system, Cone
              Ed




    94 titles, of which 5 were included in the review.      Beam Computed Tomography (CBCT), clinicians can
    Three studies used CBCT technique to 3D localize        take advantages from 3D information provided by a low
    maxillary impacted canines and assess root              radiation dose and with relatively low costs.
    resorption of adjacent teeth. Other two publications    The aim of this study was to evaluate the evidence for
    compared traditional radiographs with CBCT images       the diagnostic accuracy of CBCT in detecting impacted
    in the diagnosis of maxillary impacted canines. Only    maxillary canines and to analyze the literature focused
 IC




    three studies presented the results using statistical   on the comparison between the diagnostic effectiveness
    analysis. The present review highlighted that the       of CBCT with that of conventional radiography in the
    use of CBCT has a potential diagnostic effect and       localization of impacted maxillary canines and the
    may influence the outcome of treatment when             assessment of adjacent roots resorption.
C




    compared with traditional panoramic radiography
    for the assessment of impacted maxillary canines.
    Furthermore it underlines the need of future studies    Materials and methods
    performed according with high level methodological
©




    standards, investigating diagnostic accuracy and        The PRISMA 2009 Checklist (10) was used to conduct
    effectiveness of CBCT in the diagnosis of maxillary     this review. Only Studies that matched (at least) one
    impacted teeth.                                         of the following inclusion criteria were selected: (1)
                                                            studies that detected impacted maxillary canines with
    Key words: cone-beam computed tomography, volu-         CBCT; (2) studies that described diagnostic and/or
    metric computed tomography, maxillary impacted          therapeutic accuracy and efficacy of CBCT technique in
    canine.                                                 the diagnosis of maxillary impacted canines and incisors

    14                                                                            Annali di Stomatologia 2012; III (1): 14-18
    Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature



    roots resorption; (3) studies that compared the efficacy
    of CBCT with that of conventional radiographic images in                            PubMed, Embase
    diagnosis of impacted maxillary canines.                                              94 abstracts
    The in vitro studies were excluded. No language
    limitations were applied.




                                                                                                                   li
    The following electronic data bases were searched from
    1998 up to September 2011: PubMed and Embase.
                                                                                                       87 abstracts excluded




                                                                                                                na
    The choice of that time period was justified by the
    introduction in the late 1990s of CBCT in the clinical
    practice. The searches were not limited to particular
    types of study design so as to include all human clinical
    studies (i.e. randomized controlled trials). The following




                                                                                                             io
    keywords were used: CBCT, volumetric computed                                    7 full text publications
    tomography, impacted teeth. To determine whether the
    keywords covered all articles on the diagnostic accuracy




                                                                                   az
    of CBCT for maxillary impacted canines, the following
                                                                                                     2 publications exclude for
    journals were manually screened: The American                                                         method limits
    Journal of Orthodontics and Dentofacial Orthopedics;
    The Oral Surgery, Oral Medicine, Oral Pathology, Oral




                                                                                 rn
    Radiology and Endodontology; The European Journal of
    Orthodontics. Finally, all relevant abstracts were read,
    and the full texts of all relevant articles were collected
    and reviewed. Ambiguous articles were also read to




                                                                       te
    avoid inappropriate exclusion. All procedures were                                  5 original studies
    performed independently by two authors (GR, CC), and
    controversies were solved by reading again the articles
    and discussing them until consensus was reached.
                                                             In
                                                                        Figure 1 - Flowchart of the selection strategy used in the review.

                                                                        the proximity of the impacted canine to the lateral
    Results                                       Figure 1 ‐ Flowchartand  central
                                                                      of the       incisors,
                                                                             selection       the used
                                                                                        strategy follicleinsize, the existence of
                                                                                                            the review.
                                                  ni
                                                                        deciduous canines and the alveolar width in the canine
    A total of 94 abstracts were found using the search meth-           area. No diagnostic accuracy was described in these
    ods described. Seven abstracts were judged to meet the              three studies and the study sample was different among
                                           io


    inclusion criteria and were read in full (4,10-16). Two of          the mentioned articles.
    the collected studies were excluded for methodological              The other two publications (14,15) performed a
    limits: the first one (11) compared different radiographic          comparative analysis between traditional radiographs
                                 iz



    exams for the localization of impacted maxillary canines            and CBCT images in the diagnosis of maxillary
    of four different subjects; the other one (13) compared             impacted canines. Haney et al. (14) evaluated also
    the efficacy of CBCT images in diagnosis of maxillary im-           the diagnostic accuracy of CBCT in detecting impacted
                 Ed




    pacted canines with traditional radiographs (panoramic              maxillary canines. These Authors used as 2D traditional
    and maxillary occlusal) not generated using traditional             radiographic methods the panoramic radiographs to
    systems but obtained from CBCT data. Finally, only five             evaluate the vertical position and the occlusal x-rays to
    papers met the inclusion criteria and resulted relevant             evaluate the proximity to adjacent teeth; two periapical
    for the review (Fig.1).                                             radiographs were used to determine the labio-palatal
    Three studies (4,12,16) used CBCT imaging as the                    position. The clinicians’ confidence of the accuracy of
 IC




    standard method with the purpose to localize maxillary              diagnosis and treatment plan was statistically higher for
    impacted canines in 3D and assess root resorption of                CBCT images (P <0.001). No root resorption of adjacent
    adjacent teeth. Two of these studies (4,16) described               teeth was assessed. Alqerban et al.(15) compared
    the exact position of impacted maxillary canines and                traditional panoramic radiograph with two different CBCT
C




    their spatial relationship with neighboring anatomical              systems: 3D Accuitomo-XYZ Slice View Tomograph®
    structures using CBCT images. Only the third                        (J. Morita, Kyoto, Japan) and Scanora® 3D CBCT
    publication (12) compared the differences between                   (Soredex, Tuusula, Finland).
    the variations of impaction with a control group (30                The Authors describe the diagnostic accuracy for the
©




    normally erupted canines). While Oberoi et al.(16)                  localization of maxillary impacted canines and the
    described the localization of the maxillary impacted                detection of root resorption of maxillary incisors of these
    canines in 3D (“mesial”, “distal”, “facial”, “palatal” and          three different radiographic systems. They found that a
    “gingival” impactions) and assessed root resorption of              greater agreement between observers for all variables
    lateral incisors (“no root resorption”, “slight”, “moderate”,       was achieved when using CBCT. No statistically
    “severe” root resorption), Walker et al. (4) and Liu et al.         significant differences among the different CBCT devices
    (12) focused their attention also to the type of impaction,         were found.

    Annali di Stomatologia 2012; III (1): 14-18                                                                                        15
    G. Rossini et al.



         Authors           Sample size                          CBCT machine                     Records collected                   Results

         Walker et al.     19 patients: 16 bilateral impacted   NewTom QR-DVT 9000,              -Type of impaction –Resorption      92.6% palatal impactions.
         2005              canines, 5 left unilateral           Verona, Italy                    of incisors –Proximity of           Resorption: 66.7% lateral
                           impacted canines, 6 right                                             impacted canine to incisors –       incisors, 11.1% central incisors.
                           unilateral impacted canines                                           Follicle size –Existence of         Impacted canine side vs erupted
                                                                                                 deciduous canines –Alveolar         canine side: the alveolus was




                                                                                                                                           li
                                                                                                 width in the area of the canine –   narrower. No common location
                                                                                                 Location of impaction.              where eruption was arrested.
                                                                                                                                     Great variation in the inclination




                                                                                                                                        na
                                                                                                                                     of the impacted canine.
         Liu et al. 2008   175 patients: 210 impacted           NewTom QR-DVT 9000,              -3D variations of impaction -       Impaction: 45.2% buccal-
                           canines                              Verona, Italy                    Linear and angular                  labially, 40.5% palatally, 14.3%
                                                                                                 measurements of the inclination     in the midalveolus. Locations:
                                                                                                 and location of the impacted        67 mesial-labial, 74 mesial-
                                                                                                 teeth –Follicle size – Proximity    palatal, 31 in situ, 12 distal, 18




                                                                                                                                     io
                                                                                                 of impacted canine to incisors –    horizontal, 8 inverted. Root
                                                                                                 Resorption of incisors              resorption: 27.2% of lateral
                                                                                                                                     incisors, 23.4% of central
                                                                                                                                     incisors, 94.3% of these occurred




                                                                                                        az
                                                                                                                                     where the impacted canines were
                                                                                                                                     in close contact with the incisors.
         Oberoi et al.     29 patients: 26 bilateral impacted   Hitachi MercuRay CBCT            -3D variations of impaction –       Average degree of impaction:
         2012              canines, 16 unilateral impacted      (Hitachi Medical Corporation,    Resorption of incisors              mesial 10.1mm, distal 4.2mm,
                           canines                              Tokyo, Japan)                                                        facial 4.16mm, palatal 1.8mm,
                                                                                                                                     gingival 10mm. Root resorption




                                                                                                      rn
                                                                                                                                     of lateral incisors: 40.4% no,
                                                                                                                                     35.7% slight, 14.2% moderate,
                                                                                                                                     4% severe.

    Table 1 - Search results. CBCT localization of maxillary impacted canines and incisors root resorption.




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         Table 1 - Search results. CBCT localization of maxillary impacted canines and incisors root resorption.
    A summary of the results from the 5 articles is presented                              substantially modify the management of patients with
    in Tables 1 and 2.                                                                     potentially complex orthodontic problems.
                                                                              In           The aim of this review was to analyze the literature
                                                                                           focused on the CBCT accuracy in giving information
    Discussion                                                                             about the localization of impacted maxillary canines, and
                                                                                           to evaluate the advantages of CBCT images compared
    The advantages of 3D medical computed tomography                                       with those of conventional radiographs. Only few studies
                                                                ni

    (CT) imaging are already well established in different                                 matched the inclusion criteria of this review, differing                        1
    dental specialties: management of trauma to the                                        for the sample size and the methods used. Walker et
    maxillofacial skeleton, surgical facial reconstruction,                                al. (4), Oberoi et al. (16) and Liu et al.(12) evaluated,
                                                  io


    orthognathic surgery, dental implants, complicated                                     using CBCT data, the localization of impacted maxillary
    extractions and endodontic treatments (17-20).                                         canines and assessed lateral root resorption lesions.
    Nevertheless, its use has been limited in orthodontics                                 Walker et al.(4) collected 19 patients, ranged from 8
                                      iz



    due to high-radiation dose, high cost, lack of availability,                           to 20 years (average, 13.3; SD, 2.98), with a total of
    poor resolution and difficulty in interpretation. These                                27 impacted maxillary canines. The Authors focused
    issues may be addressed by recent CBCT innovations                                     their attention on the type of impaction, the resorption
                   Ed




    in CT technology and the use of CBCT systems could                                     of incisors, the proximity of the impacted canine to the


         Authors           Sample size                          CBCT machine                     Records collected                   Results

         Haney et al.      18 patients: 25 impacted canines     Hitachi MercuRay CBCT            –Location of impaction –Root        21% disagreement in the
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         2010                                                   (Hitachi Medical Corporation,    resorption –Orthodontic             perceived mesiodistal cusp tip
                                                                Tokyo, Japan)                    treatment plan (recover/extract)    position. 16% difference in the
                                                                                                 –Recovery vector –Expect will       perceived labiopalatal position.
                                                                                                 erupt unassisted –Expect            Perception of root resorption of
                                                                                                 additional root resorption –        adjacent teeth: 36% lack of
                                                                                                 Request for additional images       congruence. The clinicians’
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                                                                                                                                     confidence of the accuracy of
                                                                                                                                     diagnosis and treatment plan:
                                                                                                                                     statistically higher for CBCT
                                                                                                                                     images (P<0.001).
         Alqerban et al.   60 patients: 89 impacted or          -3D Accuitomo-XYZ Slice View     -Permanent maxillary canine:        Highly significant difference
©




         2011              ectopically erupting maxillary       Tomograph ® (J. Morita, Kyoto,   width of the crown, width of ht     between the 2D and 3D images
                           canines                              Japan)                           follicle, development, location,    in all variables calculated.
                                                                -Scanora ® 3D CBCT (Soredex,     angulation –Presence/absence or
                                                                Tuusula, Finland)                resorption of primary maxillary
                                                                                                 canines –Contact relationship
                                                                                                 between canines and incisors -
                                                                                                 Resorption: location and severity

    Table 2 - 2Search
       Table    - Searchresults.   Conventional
                         results. Conventional     radiographs
                                               radiographs       vsinCBCT
                                                           vs CBCT          in diagnosis
                                                                      diagnosis of maxillaryof maxillary
                                                                                             impacted     impacted
                                                                                                      canines         canines
                                                                                                              and incisors       and incisors root resorption.
                                                                                                                           root resorption.


    16                                                                                                                    Annali di Stomatologia 2012; III (1): 14-18
    Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature



    lateral and central incisors, the follicle size, the existence      conventional radiographic imaging is inadequate for the
    of deciduous canines, the alveolar width in the area of             detection of root resorption and the characterization of
    the canine, and the location of the impacted canines                resorptive lesions.
    (coronal or frontal, sagittal, axial or horizontal). The            Based on the results of this review, the following
    study sample of Liu et al.(12) comprised 175 patients               conclusions can be made:




                                                                                                               li
    with 210 impacted maxillary canines. The age range                      1) the studies on 3D localization of impacted
    was not specified. The Authors evaluated the 3D                              maxillary canines and assessment of lateral




                                                                                                            na
    variations of impaction (vertical inclination, mesio-distal                  root resorption showed that CBCT system is a
    migration, bucco-lingual crown location), linear and                         reliable method for detecting canine impaction;
    angular measurements of the inclination and location                    2) the studies on comparison between traditional
    of the impacted canines related to maxillary anatomical                      radiographs and CBCT, demonstrated that
    structures made on axial and transaxial views, based                         CBCT is superior to other radiographic methods




                                                                                                         io
    upon the methods used by Walker et al. (4). The Authors                      for visualizing the maxillofacial region and it is
    also evaluated follicle size, contact of impacted canine                     a useful aid for the diagnosis and visualization
    to the incisors and resorption of the incisors (assessed                     of the position and complications of impacted




                                                                                   az
    by axial and transaxial views and graded in 4 categories                     maxillary canines;
    based on the grading system suggested by Ericson                        3) methodological differences among selected
    and Kurol (21): no resorption: intact root surface; mild                     studies (i.e. study sample, materials and
    resorption: resorption midway to the pulp or more, the                       methods) revealed the lack of studies




                                                                                 rn
    pulp lining being unbroken; moderate resorption: the                         performed using methodological standards for
    pulp is exposed by the resorption, the involved length of                    diagnostic accuracy and effectiveness of CBCT
    the root is less than one third of the entire root; severe                   in the diagnosis of maxillary impacted teeth.
    resorption: the pulp is exposed by the resorption, and




                                                                       te
    the involved length is more than one third of the root).
    Oberoi et al.(16) analyzed 29 CBCT of orthodontic                   References
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                Ed
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    18                                                                                      Annali di Stomatologia 2012; III (1): 14-18
