Accepted: 14 March 2017

DOI: 10.1111/edt.12339

COMPREHENSIVE REVIEW

Contemporary imaging for the diagnosis and treatment of

traumatic dental injuries: A review

Nestor Cohenca1  | Adrian Silberman2

1
Department of Pediatric Dentistry, University
of Washington and Private Practice Limited to Abstract
Endodontics, Everett, WA, USA Traumatic dental injuries (TDI) have an array of presentations. Diagnostic challenges
2
Private Practice Limited to Endodontics,
are common and clinicians’ ability to correctly identify specific injuries dictates the
Murrieta, CA, USA
optimal course of treatment(s). The aim of this review was to outline and assess all
Correspondence
dental imaging techniques and their applications to traumatic dental injuries. A par-
Nestor Cohenca, Department of Pediatric
Dentistry, University of Washington and ticular interest is given to the advancement of 3D imaging techniques and their role in
Private Practice Limited to Endodontics,
diagnosis and treatment planning. The benefits of achieving a more accurate diagnosis
Everett, WA, USA.
Email: nestorendo@gmail.com are paramount to perfecting clinical judgments and outcomes.

KEYWORDS
dental trauma, diagnosis, examination, Imaging, Cone beam Computed Tomography (CBCT)

1 |  INTRODUCTION oral and maxillofacial surgery,10-12 implantology,13,14 and orthodontics

with reliable linear measurements for reconstruction and imaging of
Diagnosis is a term that takes on a broad definition as it relates to trau- dental and maxillofacial structures.15-17
matic dental injuries. The multitude of structures involved, the timing, The use of cone beam computed tomography (CBCT) in dental
the variability or lack of patient history, precedent of medical involve- traumatology was first described in 2007.18,19 Cases that may appear
ment, and the common presence of multiple, simultaneous injuries straightforward on periapical radiographs might present a different
that require equal attention provide the clinician with the challenge of and more complex situation when evaluated three-­
dimensionally
establishing priorities and distinguishing the injuries and therapies one (Figure 1). There are different techniques of 3D imaging available with
tooth at a time. The clinician must be able to distinguish between the substantial clinical applications. The clinicians’ ability to understand
injuries that have occurred in order to guide the healing in a manner and utilize these tools will assist with the diagnosis and treatment
that provides the highest level of predictability and the most favorable planning of traumatic dental injuries.
outcomes. In dental trauma, it is not necessarily the treatment that is
provided as much as an attempt to guide healing.
Imaging of the dental and maxillofacial structures has enabled 2 | ADVANCED 2D IMAGING TECHNIQUES
clinicians to visualize structural changes that provide the information
used to derive the proper diagnosis and create the treatment plan In intra-­oral digital radiography, the resolution of an image is limited
that can be implemented immediately or in stages as needed. Recent by the thickness of the layer, not the pixel size. Resolution is meas-
improvements in three-­dimensional digital radiographic imaging have ured by line pairs resolved per millimeter (lp/mm) and is also limited by
introduced a new perspective, allowing evaluation of both the hard what the human eye can detect. The detector sensitivity is the ability
1
and soft tissues, in three spatial planes. Compared to the traditional to respond to small amounts of radiation. In intra-­oral film-­based radi-
projection (plain film) radiograph, which is a two-­dimensional shadow ography, the sensitivity is directly related to the film speed. The sensi-
of a three-­
dimensional object, 3D imaging overcomes this major tivity of the digital sensors is affected by pixel size and system noise.
limitation by providing a true representation of the anatomy while Although photostimulable phosphors (PSP) systems allow dose reduc-
eliminating super-­impositions. Several studies have reported the use tions close to 50% compared with F-­speed film, the charge-­coupled
of computerized tomography and digital radiography for differential devices/complementary metal oxide semiconductors (CCD/CMOS)
diagnosis,2-4 assessment of treatment outcomes,5,6 endodontics,3,7-9 sensors have less dose reduction than PSP systems. Modulation

Dental Traumatology. 2017;33:321–328. wileyonlinelibrary.com/journal/edt   © 2017 John Wiley & Sons A/S. |  321
Published by John Wiley & Sons Ltd
 |
322       COHENCA and SILBERMAN

(A) (B) (C)

F I G U R E   1   (A-­B) Two periapical radiographs taken at different angles demonstrate the presence of complicated crown fractures of the
maxillary right central and lateral incisors. (C) A sagittal view of the maxillary right lateral incisor reveals the presence of a crown-­root fracture
(see arrow) that was not diagnosed using conventional 2D imaging

transfer factor (MTF) is a measure of the combined sharpness and res- or background noise. With an increase in the “noise,” there is a de-
olution factors. Generally, the MTF of fast films is superior to the MTF crease in contrast, which may affect the ability to properly interpret
of PSP at high spatial frequencies, which explains the sharpness and the image(s). The anatomical noise may also account for an under-­
higher resolution of E-­or F-­speed films compared with PSP plates. In estimation of periapical radiolucency size on radiographic images26,27
terms of contrast, the displayed image provides up to 8 times more and this would suggest an influence in the ability to properly account
information than the human eye can actually resolve.20 for the details necessary to properly evaluate and diagnose traumatic
It is important to note that diagnosis is knowledge based and re- dental injuries. The root apices of maxillary incisors, the area most
quires training. A clinician must know normal anatomy to identify ab- prone to traumatic injury, lie very close to the adjacent cortical plate,
normalities and features that may be diagnostic. Detector resolution, so anatomical noise would be less of a factor although it must still be
exposure factors, and display systems that enhance or reduce image considered.
quality are secondary to foundation concepts. Despite their limitations, periapical (PA) radiographs combined
with clinical examination remains the standard of care and should al-
ways be considered during the initial evaluation of the patient. The
3 |  LIMITATIONS OF CONVENTIONAL information obtained will determine the need for and the specific tar-
2D RADIOGRAPHY IN DENTAL AND get of 3D imaging, particularly in cases of root fractures and lateral
MA XILLOFACIAL TRAUMA luxations, monitoring of healing, and complications.28,29 The combina-
tion of different 2D angles may not be a correct reflection of the true
Conventional images compress three-­
dimensional anatomy into anatomy present but will be a basis to determine whether 3D imaging
a two-­
dimensional image or shadowgraph. Reading two of three is necessary.
planes, mathematically means 66% of the imaged structures are
in the visible field. Brynolf’s classic studies found that radiographs
taken from varied angles resulted in better perception of depth and 4 | 3D IMAGING TECHNIQUES
spatial relationship of periapical radiolucencies associated with root
apices.21-24 Diagnostic information in the missing “third dimension” Three-­dimensional imaging includes a wide range of techniques, in-
is of particular relevance in traumatic injuries where the angulation cluding computed tomography (CT), magnetic resonance imaging
of the root to the cortical plate, the thickness of the cortical plate, (MRI), and cone beam computed tomography (CBCT). The value of
and the relationship of the root to key adjacent anatomical structures both CT and MRI in major maxillofacial injuries, pathology, and re-
such as the inferior alveolar nerve, mental foramen, or maxillary sinus constructive surgery is well established, whereas CBCT has become a
should be clearly visualized and interpreted. Anatomical features may recommended technology in diagnosis of TDI’s due to its low radiation
obscure the area of interest resulting in difficulty interpreting radio- dosimetry, high resolution, flexibility on its field of view (FOV), and
graphic images.25 This effect is given the term anatomical, structured, equipment cost.
COHENCA and SILBERMAN |
      323

(A) (B)

F I G U R E   2   (A-­B) Clinical photographs

of the maxillary left central incisor obtained
immediately after trauma. (C-­D) Fractured
and loose fragments were removed,
and the suitability for restoration was
(C) (D)
questionable

linear measurements for reconstruction and imaging of dental and max-

5 | CONE BEAM COMPUTED
illofacial structures.34-36
TOMOGRAPHY

Cone beam computed tomography, also called digital volume tomog-

raphy (DVT), is a new technique that produces a three-­dimensional 6 | COMPARISON BETWEEN 3D IMAGING
digital imaging at reduced cost and less radiation for the patient than TECHNIQUES
traditional CT scans.12 It also delivers a faster and easier image ac-
quisition. CBCT differs from CT in that the entire three-­dimensional CBCT results in a fraction of the effective absorbed dose of radia-
volume of data is acquired during a single sweep of the scanner, using tion (E) compared to traditional CT scans. Imaging of the maxillo-­
a simple, direct relationship between sensor and source, which rotate mandibular region with the NewTom 3G results in an E of 57 μSv37
in synchrony around the patient’s head. while traditional medical CT’s result in an E of 1400 μSv for a maxil-
The NewTom 3G DVT 9000 (Quantitative Radiology s.r.l., Verona, lary CT scan and 2100 μSv for a maxillo-­mandibular scan.38 For the
Italy) was first introduced for imaging of the dental and maxillofacial purposes of comparison, a panoramic radiograph results in an E of
region in 1997. Since then, the technology has evolved with cur- 6 μSv and a full mouth series of PA radiographs results in an E from
rently more than 50 different companies and between 2000 and 33-­84  μSv39 and 14-­100 μSv40 depending upon variables such as film
2500 CBCT units being installed in the United States per calendar speed, technique, kVp, and collimation.
year.30 Different studies have shown that the field size (small, medium,
CBCT scanners are based on volumetric tomography using a 2D and large) is directly correlated with the effective dose.31,41,42 The av-
­extended digital array providing an area detector combined with a 3D erage doses for large, medium, and small field of views (FOV) were
X-­ray beam. The cone beam technique involves a single 360° scan in 131, 88, and 34 υSv, respectively.41 Thoughtful selection of the FOV,
which the X-­
ray source and a reciprocating area detector synchro- region of interest, and resolution is needed to optimize the diagnostic
nously move around the patient’s head, which is stabilized with a head information and to reduce the patient dose.
holder. At certain degree intervals, single projection images, known as Spatial resolution is the second significant advantage of CBCT
“basis” images, are acquired. These are similar to lateral cephalometric when compared to CT. CBCT units in general provide voxel reso-
radiographic images, each slightly offset from one another. This series lutions that are isotropic, equal in all three orthogonal dimensions
31
of basis projection images is referred to as the projection data. CBCT unlike the spatial resolution of many conventional CT images in
units can be classified according to the imaged volume or field of view which the resolution along the axial or scanning direction is some-
(FOV) as large FOV (6 inch-­12 inch or 15-­30.5 cm) or limited FOV sys- times significantly lower than in the transverse direction, referred to
tems (1.6 inch-­3.1 inch or 4-­8 cm).32 Dental applications of CBCT have as anisotropic.31 Most CBCT scans are capable of producing high-­
10-12 13,14
been reported for oral and maxillofacial surgery, implantology, resolution images ranging between 75 and 400 υm compared with
orthodontics,15-17 endodontics,9 and periodontics.33 Studies have sug- 800-­2,100  υm with CT and 316 υm with MRIs.19 The reduction in
gested that digital volume tomography provides accurate and reliable anatomical noise and high contrast resolution allows differentiation
 |
324       COHENCA and SILBERMAN

F I G U R E   3   (A-­B) Sagittal views define

the extension and direction of the fractures
as well as determining the crown-­root ratio
(A) (B)
to help treatment planning

of tissues <1% physical density difference to be distinguished com- management of any pulp injury will be based on the basic concepts
pared to the 10% physical density difference required with conven- of endodontics, such as preservation of the pulp if possible when the
tional radiography.43 tooth/root lacks development or endodontic therapy to prevent in-
fection and to promote healing. Vital pulp therapies should always be
considered in situations where further root development and matura-
tion is desired. In mature teeth, where orthodontic extrusion is indi-
7 | DENTAL TRAUMA AND 3D IMAGING
cated, endodontic therapy should usually be performed.

Periapical radiographs combined with a thorough clinical examination

remain the standard of care and should always be considered during
the initial evaluation of the patient. Three-­dimensional imaging should 9 | ROOT FRACTURES
be considered in cases in which further imaging is required to ob-
tain an accurate diagnosis and to develop the correct treatment plan. Root fractures are isolated to the radicular portion of the tooth af-
Current guidelines published by the International Association of Dental fecting cementum, dentin, and pulp with collateral effects to the peri-
Traumatology (IADT) recommend considering the need for CBCT based odontium. Root fractures present a diagnostic challenge due to the
28,29 limitations of 2D images such as projection geometry, superimposition
on the type and severity of the dental and maxillo-­facial injury.
of anatomical structures, and processing errors.18,29,44,45 Thus, taking
multiple periapical radiographs at various angles (45°, 90°, 110°) has
8 | CROWN-­R OOT FRACTURES been recommended.46 A retrospective clinical study reported that
when periapical radiographs were used, the detection rate of root
Injuries in this category involve the enamel, dentin, and cementum. fractures reached only 30%-­40% of cases, compared to a 90% detec-
The pulp may or may not be exposed as a result of injury. The diagno- tion rate when using CBCT (Figure 4).47
sis of a crown-­root fracture involves a careful analysis of the tooth and A recent clinical study reported that in 68.2% of the cases the
the periodontium. The dental fragment may be fractured but may still horizontal fracture was located in the middle third of the root and
be connected to the periodontal ligament fibers. The fragment(s) may extended toward the cervical third on the palatal aspect (Figure 5).48
be mobile and quite sensitive. Accurate determination of the apical As fractures located at the cervical third are considered to have the
extent of the fracture is not always possible when using 2D periapical poorest prognosis, failure to identify the cervical extension could lead
radiographs, and thus, the use of CBCT to evaluate the location and to improper treatment and unfavorable outcomes.
19
extension of the fracture is strongly recommended. One of the most CBCT should be strongly considered in cases in which conven-
important factors to be considered is the crown-­root ratio and the tional radiography yields inconclusive results or shows a fracture in
suitability of the remaining tooth structure for restoration (Figure 2). the middle third of a root.49 In such cases, CBCT may rule out false
Treatment options include surgical crown lengthening, orthodontic negatives, that is, a suspected root fracture not visualized with con-
extrusion, submergence, and extraction. If the fracture extends below ventional radiography. For root fractures in the middle third, CBCT
the osseous level and the remaining root length provides a positive may rule out or confirm an oblique extension of the fracture involving
crown-­root ratio (Figure 3), the long-­term prognosis is favorable. The the cervical third in the bucco-­lingual dimension. Accurate diagnosis
COHENCA and SILBERMAN |
      325

(A) (B)

F I G U R E   4   (A-­B) Periapical radiographs

of the maxillary right and left central
incisors and maxillary left lateral incisor.
The images were not conclusive regarding
the type of injury. (C-­E) Coronal and
sagittal views demonstrate horizontal
root fractures of both maxillary central
incisors and a crown-­root fracture of the
maxillary left lateral incisor (Courtesy of Dr.
(C) (D) (E)
Sebastian Ortolani)

F I G U R E   5   (A) Axial and (B) sagittal

views of a horizontal root fracture with an
oblique extension on the palatal surface
of the root of the maxillary right central
(A) (B)
incisor

will provide critical information needed for the development of a com- Regardless of the direction of displacement, luxation injuries
prehensive and appropriate treatment plan. cause severe damage to the periodontium and they often occur with
concomitant alveolar fractures. This is particularly true in cases of lat-
eral luxation in which the crown is displaced lingually/palatally and
10 |  LUXATION INJURIES the apical third is displaced buccally. To properly manage these inju-
ries, an accurate diagnosis is required. As the movements and sub-
Luxation is defined as an injury to the supporting tissues with loosen- sequent displacements are mostly in the sagittal plane, intra-­oral 2D
ing and clinical and/or radiographic displacement. The terms luxation, radiographs will not always reveal the severity of the injury (Figure 6).
displacement, and dislocation refer to the same injury. The luxation may Failure to diagnose alveolar fractures may lead to incorrect treatment
be intrusive, lateral, extrusive, or a combination of these. The degree of planning and more complications, particularly pulp necrosis and in-
displacement can range from mild to severe, depending on the intensity fection.50 Moreover, failure to reposition the tooth correctly may lead
and the direction of the forces absorbed by the hard and soft tissues. to poor alveolar healing and chronic pain due to apical fenestration.
 |
326       COHENCA and SILBERMAN

(A) (B)

(C) (D) (E)

F I G U R E   6   (A-­B) Clinical photographs of the maxillary left central incisor. The patient had repositioned the tooth. (C-­D) Periapical radiographs at
different angles demonstrating what appeared to be a well-­repositioned tooth, especially when combined with the clinical appearance. (E) A lateral
view of the volumetric 3D reconstruction reveals the presence of an alveolar buccal fracture with involvement of the apical portion of the root

(A) (B) (C) (D)

(E) (F) (G) (H)

F I G U R E   7   (A-­B) Periapical radiographs of the maxillary left and right central incisors, 2 weeks postavulsion and replantation within
20 minutes. (C-­D) Radiographs taken at 6-­month follow-­up demonstrate root development, indicating a viable pulp. (E-­F) At 2-­year follow-­up,
root development is complete for the maxillary left central incisor, but unclear on the maxillary right central incisor (see arrow). (G-­H) Coronal
and sagittal views confirm healing of the apical tissues with ingrowth of bone into the root canal and the unusual formation of the apical portion
of the root (see arrows)
COHENCA and SILBERMAN |
      327

possibilities, as well as collecting, analyzing, and interpreting all the rele-

11 |  APPLICATION OF CBCT IMAGING
vant information gathered. Diagnostic tests, including all types of imaging,
are aimed at identifying an injury or disease, but they are equally import-
While there is no debate regarding the benefits of CBCT in dental and
ant at ruling out the possible presence of other injuries. As hard as it might
maxillo-­facial trauma, all clinicians should be aware of, and apply the
be to understand, having no additional findings as a result of 3D imaging
principles of ALARA (As Low As Reasonable Achievable) for recom-
is still a very important finding since being able to confirm the absence
mended radiologic exposures when using CBCT or any other imaging
of a disease or injury is as paramount as diagnosing one. There is equal
technique. To minimize radiation exposure while maximizing diagnos-
value when a clinician identifies a suspected injury and when an injury
tic information, clinicians should consider the use of CBCT only when
can be ruled out as they both provide the groundwork for treatment and
the need for information cannot be obtained adequately by lower
expected outcomes. Thus, the fact that no new findings were obtained by
dose conventional dental radiography or alternate imaging modalities.
the imaging prescribed does not mean that the scan was not indicated.
If 3D imaging is indicated, clinicians should always consider using the
When indicated, 3D imaging in general and CBCT in particular pro-
smallest field of view (FOV) necessary to scan the traumatized tis-
vide valuable data to diagnose, understand, develop a treatment plan,
sues. Small FOV produces higher resolution images at lower radiation
and make informed clinical decisions that improve the outcomes in
dose. This is particularly important in children considering they are at
ways that are predictable and demonstrable.
greater risk than adults from a given dose of radiation because they
are both inherently more radiosensitive and they have more remaining
CO NFL I C T O F I NT ER ES T
years of life during which a radiation-­induced cancer could develop.51
Modern 3D imaging techniques provide the third dimension that The authors confirm that they have no conflict of interest.
may not be clinically obvious chairside. Traumatic dental injuries are
often more complex and involve several tissues, besides the dental
REFERENCES
structures. The utilization of 3D imaging helps define the complexities,
1. Scarfe WC. Imaging of maxillofacial trauma: evolutions and emerg-
and reveal this otherwise hidden information, which may assist in un-
ing revolutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
derstanding the type of injuries sustained and the treatment(s) needed.
2005;100:S75-S96.
CBCT technology should also be considered for follow-­up exam- 2. Shrout MK, Hall JM, Hildebolt CE. Differentiation of periapical granu-
inations. Often, clinical and 2D radiographic examinations may not lomas and radicular cysts by digital radiometric analysis. Oral Surg Oral
be sufficient to determine the presence or absence of pulp and peri- Med Oral Pathol. 1993;76:356-361.
3. Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry M, Patel A.
odontium healing (Figure 7A-­F). In such cases, the use of CBCT may
Differential diagnosis of large periapical lesions using cone-­beam com-
provide the necessary evidence leading to a definitive diagnosis and puted tomography measurements and biopsy. J Endod. 2006;32:833-837.
treatment, if needed (Figure 7G-­H). 4. Trope M, Pettigrew J, Petras J, Barnett F, Tronstad L. Differentiation
Development of new and more sophisticated algorithms has al- of radicular cyst and granulomas using computerized tomography.
Endod Dent Traumatol. 1989;5:69-72.
lowed for significant improvements in imaging software. New tools
5. Camps J, Pommel L, Bukiet F. Evaluation of periapical lesion healing by
and features include finite measurements, soft and hard tissue recon- correction of gray values. J Endod. 2004;30:762-766.
structions, surgical guides, and even echography. Changes in the width 6. Cotti E, Vargiu P, Dettori C, Mallarini G. Computerized tomography in
of the periodontal ligament space may indicate the luxation of a tooth the management and follow-­up of extensive periapical lesion. Endod
Dent Traumatol. 1999;15:186-189.
in a plane that may not have been identified when viewed from a sin-
7. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG.
gle plane with traditional digital radiography. New software provides a Endodontic applications of cone-­ beam volumetric tomography.
detailed model from which future comparative data may be gathered J Endod. 2007;33:1121-1132.
to show resolution or progression of deleterious processes. 8. Rosen E, Taschieri S, Del Fabbro M, Beitlitum I, Tsesis I. The Diagnostic
efficacy of cone-­ beam computed tomography in endodontics: a
systematic review and analysis by a hierarchical model of efficacy.
12 |  DISCUSSION J Endod. 2015;41:1008-1014.
9. Special committee to revise the Joint AAEAPSouoCiE. AAE and AAOMR
joint position statement: use of cone beam computed tomography in
A definitive diagnosis can only be obtained after evaluating the results endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol.
of all available and relevant tests, including a comprehensive clinical 2015;120:508-512.
and radiographic evaluation. In dental traumatology, this means ana- 10. Danforth RA, Peck J, Hall P. Cone beam volume tomography: an imag-
ing option for diagnosis of complex mandibular third molar anatomical
lyzing multifactorial data. Although 3D imaging provides a completely
relationships. J Calif Dent Assoc. 2003;31:847-852.
new geometrical plane and dimension, it should never replace the 11. Eggers G, Mukhamadiev D, Hassfeld S. Detection of foreign bodies
standard clinical and radiographic evaluations (including 2D imaging). of the head with digital volume tomography. Dentomaxillofac Radiol.
The progression of 3D technology has provided a user-­friendly, ef- 2005;34:74-79.
12. Ziegler CM, Woertche R, Brief J, Hassfeld S. Clinical indications
ficient, and important tool for proper diagnosis. When evaluating a pa-
for digital volume tomography in oral and maxillofacial surgery.
tient with traumatic maxillo-­facial injuries, clinicians should begin with the
Dentomaxillofac Radiol. 2002;31:126-130.
concept that any accident may produce many and varied types of inju- 13. Hatcher DC, Dial C, Mayorga C. Cone beam CT for pre-­surgical as-
ries. Proper diagnosis is made after considering all differential diagnostic sessment of implant sites. J Calif Dent Assoc. 2003;31:825-833.
 |
328       COHENCA and SILBERMAN

14. Sato S, Arai Y, Shinoda K, Ito K. Clinical application of a new cone-­ 35. Lascala CA, Panella J, Marques MM. Analysis of the accuracy of lin-
beam computerized tomography system to assess multiple two-­ ear measurements obtained by cone beam computed tomography
dimensional images for the preoperative treatment planning of (CBCT-­NewTom). Dentomaxillofac Radiol. 2004;33:291-294.
maxillary implants: case reports. Quintessence Int. 2004;35:525-528. 36. Marmulla R, Wortche R, Muhling J, Hassfeld S. Geometric accuracy of the
15. Baumrind S, Carlson S, Beers A, Curry S, Norris K, Boyd RL. Using NewTom 9000 Cone Beam CT. Dentomaxillofac Radiol. 2005;34:28-31.
three-­dimensional imaging to assess treatment outcomes in ortho- 37. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral
dontics: a progress report from the University of the Pacific. Orthod direct digital imaging devices: NewTom cone beam CT and Orthophos
Craniofac Res. 2003;6(Suppl 1):132-142. Plus DS panoramic unit. Dentomaxillofac Radiol. 2003;32:229-234.
16. Danforth RA, Dus I, Mah J. 3-­D volume imaging for dentistry: a new 38. Ngan DC, Kharbanda OP, Geenty JP, Darendeliler MA. Comparison of
dimension. J Calif Dent Assoc. 2003;31:817-823. radiation levels from computed tomography and conventional dental
17. Maki K, Inou N, Takanishi A, Miller AJ. Computer-­assisted simulations radiographs. Aust Orthod J. 2003;19:67-75.
in orthodontic diagnosis and the application of a new cone beam 39. Danforth RA, Clark DE. Effective dose from radiation absorbed during
­X-­ray computed tomography. Orthod Craniofac Res. 2003;6(Suppl a panoramic examination with a new generation machine. Oral Surg
1):95-101. discussion 179-182. Oral Med Oral Pathol Oral Radiol Endod. 2000;89:236-243.
18. Cohenca N, Simon JH, Mathur A, Malfaz JM. Clinical indications for 40. Gibbs SJ. Effective dose equivalent and effective dose: comparison
digital imaging in dento-­alveolar trauma. Part 2: root resorption. Dent for common projections in oral and maxillofacial radiology. Oral Surg
Traumatol. 2007;23:105-113. Oral Med Oral Pathol Oral Radiol Endod. 2000;90:538-545.
19. Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Clinical indica- 41. Pauwels R, Beinsberger J, Collaert B, et al. Effective dose range for
tions for digital imaging in dento-­alveolar trauma. Part 1: traumatic dental cone beam computed tomography scanners. Eur J Radiol.
injuries. Dent Traumatol. 2007;23:95-104. 2012;81:267-271.
20. Cederberg RA, Frederiksen NL, Benson BW, Shulman JD. Influence 42. Qu XM, Li G, Ludlow JB, Zhang ZY, Ma XC. Effective radiation dose
of the digital image display monitor on observer performance. of ProMax 3D cone-­beam computerized tomography scanner with
Dentomaxillofac Radiol. 1999;28:203-207. different dental protocols. Oral Surg Oral Med Oral Pathol Oral Radiol
21. Brynolf I. Roentgenologic periapical diagnosis. IV. When is one roent- Endod. 2010;110:770-776.
genogram not sufficient? Swed Dent J. 1970;63:415-423. 43. White SC, Pharoah MJ. Advanced Imaging Modalities. In: White SC,
22. Brynolf I. Roentgenologic periapical diagnosis. 3. The more Pharoah MJ, eds. Oral Radiology: Principles and interpretation, 6th edn.
roentgenograms-­ the better the information? Swed Dent J. St Louis, Missouri: Elsevier Health Sciences; 2009:207-229.
1970;63:409-413. 44. Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the man-
23. Brynolf I. Roentgenologic periapical diagnosis. II. One, two or more agement of traumatic dental injuries. I. Fractures and luxations of per-
roentgenograms? Swed Dent J. 1970;63:345-350. manent teeth. Dent Traumatol. 2007;23:66-71.
24. Brynolf I. Roentgenologic periapical diagnosis. I. Reproducibility of 45. Palomo L, Palomo JM. Cone beam CT for diagnosis and treatment
interpretation. Swed Dent J. 1970;63:339-344. planning in trauma cases. Dent Clin North Am. 2009;53:717-727.
25. Revesz G, Kundel HL, Graber MA. The influence of structured 46. Feiglin B. Clinical management of transverse root fractures. Dent Clin
noise on the detection of radiologic abnormalities. Invest Radiol. North Am. 1995;39:53-78.
1974;9:479-486. 47. Bernardes RA, de Moraes IG, Hungaro Duarte MA, Azevedo BC,
26. Bender IB, Seltzer S. Roentgenographic and direct observation of ex- deAzevedo JR, Bramante CM. Use of cone-­beam volumetric tomog-
perimental lesions in bone: II. 1961. J Endod. 2003;29:707-712. raphy in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol
27. Bender IB, Seltzer S. Roentgenographic and direct observation of ex- Oral Radiol Endod. 2009;108:270-277.
perimental lesions in bone: I. 1961. J Endod. 2003;29:702-706. 48. Bornstein MM, Wolner-Hanssen AB, Sendi P, von Arx T. Comparison
28. Andersson L, Andreasen JO, Day P, et al. International Association of intraoral radiography and limited cone beam computed tomog-
of Dental Traumatology guidelines for the management of trau- raphy for the assessment of root-­fractured permanent teeth. Dent
matic dental injuries: 2 Avulsion of permanent teeth. Dent Traumatol. Traumatol. 2009;25:571-577.
2012;28:88-96. 49. May JJ, Cohenca N, Peters OA. Contemporary management of hori-
29. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International zontal root fractures to the permanent dentition: diagnosis-­radiologic
Association of Dental Traumatology guidelines for the management assessment to include cone-­ beam computed tomography. Pediatr
of traumatic dental injuries: 1. Fractures and luxations of permanent Dent. 2013;35:120-124.
teeth. Dent Traumatol. 2012;28:2-12. 50. Lauridsen E, Gerds T, Andreasen JO. Alveolar process fractures in the
30. Hatcher DC. Operational principles for cone-­beam computed tomog- permanent dentition. Part 2. The risk of healing complications in teeth in-
raphy. J Am Dent Assoc. 2010;141(Suppl 3):3S-6S. volved in an alveolar process fracture. Dent Traumatol. 2016;32:128-139.
31. Scarfe WC, Li Z, Aboelmaaty W, Scott SA, Farman AG. Maxillofacial 51. Scarfe WC. “All that glitters is not gold”: standards for cone-­beam
cone beam computed tomography: essence, elements and steps to computerized tomographic imaging. Oral Surg Oral Med Oral Pathol
interpretation. Aust Dent J. 2012;57(Suppl 1):46-60. Oral Radiol Endod. 2011;111:402-408.
32. Tetradis S, Anstey P, Graff-Radford S. Cone beam computed to-
mography in the diagnosis of dental disease. J Calif Dent Assoc.
2010;38:27-32. How to cite this article: Cohenca N, Silberman A.
33. Korostoff J, Aratsu A, Kasten B, Mupparapu M. Radiologic assessment
Contemporary imaging for the diagnosis and treatment of
of the periodontal patient. Dent Clin North Am. 2016;60:91-104.
traumatic dental injuries: A review. Dent Traumatol.
34. Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear
temporomandibular joint measurements with cone beam computed 2017;33:321–328. https://doi.org/10.1111/edt.12339
tomography and digital cephalometric radiography. Am J Orthod
Dentofacial Orthop. 2005;128:803-811.