Odontology
DOI 10.1007/s10266-013-0144-z
ORIGINAL ARTICLE
Comparative assessment of periapical radiography and CBCT
imaging for radiodiagnostics in the posterior maxilla
Maryam Shahbazian Charlotte Vandewoude
Jan Wyatt Reinhilde Jacobs
Received: 4 March 2013 / Accepted: 14 December 2013
The Society of The Nippon Dental University 2013
Abstract Close proximity of the maxillary roots and the
sinus floor makes a dental disease a probable cause of
maxillary sinusitis. The aim of this study was to evaluate
the ability of periapical radiography and cone beam com-
puted tomography in defining the topographic relationship
of maxillary teeth to the sinus floor and detecting apical
periodontitis and other odontogenic causes of the maxillary
sinusitis. Out of 145 dental records from subjects (mean
age 52 years, range 2075 years; 89 females) referred to
the Oral Imaging Centre, KU Leuven, periapical and
CBCT images of the posterior maxilla were selected for
further analysis. Anatomical relationship of maxillary teeth
to the sinus floor, apical periodontitis and other etiological
causes of soft tissue thickening were assessed with both
imaging modalities. The results of this study demonstrated
that periapical radiographs are not adequate in observing
the anatomical relationship between maxillary molars and
the sinus floor. CBCT showed an intimate relationship of
1st and 2nd molar with the maxillary sinus in 50 and 45 %
of the cases, respectively. Periapical radiography could
only spot approximately 40 % of apical periodontitis on
M. Shahbazian (&)
C. Vandewoude
R. Jacobs
OMFS-IMPATH Research Group, Department of Imaging and
Pathology, Faculty of Medicine, University of Leuven-KU
Leuven, Leuven, Belgium
e-mail: maryam.shahbazian@med.kuleuven.be
J. Wyatt
Pediatric Dentistry and Special Care, Department of Oral Health
Sciences, University of Leuven and Dentistry, University
Hospitals Leuven, Leuven, Belgium
R. Jacobs
Oral and Maxilla-Facial Surgery, University Hospitals Leuven,
Leuven, Belgium
posterior maxillary teeth and 3 % of all apical infections
extending to the sinus, seen on CBCT.
Keywords CBCT
Periapical
Maxillary sinus

Maxillary molars
Apical periodontitis
Introduction
The topographic relation of the inferior wall of the max-
illary sinus with the maxillary root apices varies according
to an individuals age, dental status, size and pneumatiza-
tion of the maxillary sinus [1, 2]. Because of the close
proximity of maxillary roots to the sinus floor, conditions
that violate the integrity of the bony cavity of the maxillary
sinus or the Schneiderian membrane, such as periodontal
disease, surgical procedure, pulpal infection and end-
odontic therapy in this region, can have a profound effect
on the maxillary sinus [3]. As bacteria are introduced into
the maxillary sinus, symptoms will gradually increase with
the development of sinusitis [4, 5]. If left untreated, these
infections of odontogenic origin can progress and lead to
serious complications such as spreading into orbital and
cranial structures [6, 7]. Considering the significant risk for
odontogenic sinusitis and the wide variation in its symp-
toms and clinical findings, the importance of a correct
diagnosis is obvious [8, 9]. It directly influences clinical
decisions and might offer a better treatment planning, and
potentially a more predictable outcome [10, 11]. Clinical
examination and periapical (PA) radiographs are standard
diagnostic tools to assess periapical periodontitis. Radio-
graphic examination is considered as an essential part of
the diagnosis and the management of endodontic problems
[12]. However, PA radiographs show a limited field of
view, suffering from superimposition of three-rooted
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maxillary teeth and the zygomatic process on the sinus
floor [12]. Therefore, the relationship of the root(s) to the
maxillary sinus, potential periodontal or peri-apical
pathology and any related osseous or mucosal changes
cannot always be truly assessed with conventional
radiographs.
Throughout recent years, introduction of the CBCT for
dentomaxillofacial diagnostics has allowed producing
detailed three-dimensional views of jaw bones, teeth and
related pathologies. Some studies have indicated that
CBCT may provide promising results with a more accurate
detection of apical periodontitis [1319]. Yet, up till now,
few studies have compared the diagnostic value of cone
beam computed tomography (CBCT) and PA radiography
in detecting sinus-related apical periodontitis [13, 20, 21].
Therefore, the present study was performed to compare
the ability of digital periapical radiography and CBCT in
defining the topographic relationship of the maxillary teeth
on the sinus floor and in detecting apical periodontitis and
other pathological causes, which can cause maxillary
sinusitis.
Materials and methods
The dental records of the patients referred between Feb-
ruary 2008 and May 2010 to the Oral Imaging Centre
(University Hospitals Leuven, Leuven, Belgium) for dif-
ferent treatment procedures were examined. The inclusion
criteria were patients older than 18 years, visible imaging
of posterior maxillary teeth, examined with both periapical
and CBCT imaging with a maximum 3-month interval.
Based on these inclusion criteria, periapical radiographs
and CBCT images of 145 subjects (89 females, 56 males;
mean age 52 years, range 2075 years) could be identified.
A total of 537 teeth were selected for the study, 219 molars,
220 premolars and 98 canines. Ethical approval was
obtained by the local Clinical Trial Center and Ethical
Board (University Hospitals, KU Leuven).
Digital periapical radiographs were obtained with a
wall-mounted MinRay (Soredex, Tuusula, Finland)
operating at 65 kV, 7 mA and exposure time of 0.10 s.
Considering the retrospective nature of the study with
consecutive patient recruitment fitting the inclusion crite-
ria, the data from two different CBCT scans were included
in this study. The inclusion of two CBCT devices resulted
from the differential indications for both devices, one being
a high-resolution system for endodontics, trauma, resorp-
tion diagnosis and specific bone pathology observations,
while the other one is a low-dose CBCT system typically
used for pre-operative planning of implant placement.
Most images (n = 130) were acquired using a low-dose
Scanora 3D (Soredex, Tuusula, Finland), with a voxel
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Odontology
size of 0.2 mm (field of volume 75 9 100 mm), tube
voltage of 85 kV, current of 8 mA, and exposure time of
3.7 s. The remaining images (n = 15) were obtained with
high-resolution 3D Accuitomo170 (J. Morita MFG
CORP, Kyoto, Japan) operated with a voxel size of
0.125 mm (field of view 60 9 60 mm), a tube voltage of
90 kV, a tube current of 5 mA, and a scanning time of
17.5 s.
From the CBCT acquisition, multiplanar reformatted
reconstructions in the axial planes were created. Each scan
was reviewed in axial, sagittal, coronal, cross-sectional and
panoramic view for observing relationship between the
maxillary teeth and the sinus floor, soft tissue thickening,
and the cause of soft tissue thickening. For assessing the
anatomical relationship, a single score was obtained for
each (single or multi-rooted) tooth for both CBCT and
periapical radiography using the following types:
1. There is a distinct distance between the root tip and the
sinus floor.
2. The roots are in close contact with the inferior border
of the maxillary sinus (\0.5 mm distance).
3. The roots are projecting laterally over the sinus but
root tips are outside the sinus.
4. The roots are in intimate relationship with the sinus
floor. There is no bony coverage between the root tips
and the sinus floor (Fig. 1).
In the multi-rooted teeth, the intimate relationship was
scored if one root at least had an intimate relationship with
maxillary sinus. In the presence of apical periodontitis
perforating the sinus floor, the anatomical relationship
between maxillary teeth and the sinus floor was defined as
the distance between the root tips and the line, which
defines the border of the sinus floor.
In addition, proximity of the lesions to the sinus floor
and possible perforation of the sinus floor was classified
into 3 different groups:
1. A distinct distance between the sinus floor and the
apical lesion.
2. A lesion in close contact (\1 mm) with the maxillary
sinus with a clearly demarcated bony wall.
3. A lesion without bony converge with the maxillary
sinus and perforating into the sinus.
Perforation of the sinus floor was defined as an apical
radiolucency that extends from an infected tooth root or
socket directly into the sinus. Pathologic soft tissue thick-
ening was defined as a soft tissue exceeding 3 mm [22, 23].
In the case of a diagnosis of soft tissue thickening, the
possible etiologic cause was recorded. Based on the pre-
sence or absence of soft tissue thickening, the maxillary
sinus was classified into four categories based on a modi-
fied classification by Maillet et al. [24]: normal sinus,
Odontology
Fig. 1 ad CBCT images and eh corresponding periapical images
of the classification of maxillary posterior teeth relationship to the
inferior wall of the sinus; distinct distance between teeth 14 and 15
root tips and maxillary sinus floor shown in CBCT (a) and periapical
radiography (e) close contact between root tips of tooth 17 and
tooth-associated soft tissue thickening, sinus with soft tis-
sue thickening of rhinogenic origin, and sinus with soft
tissue thickening of mixed origin.
Normal sinus was indicated if there was no soft tissue
thickening detected on the images, or it was \3 mm.
Tooth-associated soft tissue thickening was indicated with
a soft tissue density mass within the sinuses limited to the
tooth area, related to the pathology of the tooth or tooth
extraction site. Odontogenic causes of soft tissue thicken-
ing were classified as apical periodontitis, periodontal
disease and iatrogenic causes such as extraction site,
remnant roots, foreign bodies or implants. Apical peri-
odontitis was defined as periapical radiolucency in con-
nection with the apical part of the root exceeding at least
twice the width of the periodontal ligament space (Fig. 2).
For the CBCT images, the same criteria were applied, and
the lesion had to be visible in more than 1 of the image
planes. Periodontal disease was noted based on the peri-
odontal breakdown of the alveolar bone, potentially
extending into the furcation of multi-rooted teeth. Widen-
ing of the periodontal ligament space at the apex of the
interradicular bony crest of the furcation was considered as
an evidence of furcation involvement [25]. Soft tissue
thickening of rhinogenic origin was selected when
observing a significant and generalized soft tissue density
mass within the sinuses (and potentially other sinuses), not
having a focal character by being localized in the vicinity
maxillary sinus floor shown in CBCT (b) and periapical radiography
(f), lateral projection of the root tip of tooth 15 on the maxillary sinus
floor shown in CBCT (c) and periapical radiography (g), intimate
relationship between palatal root tip of tooth 16 and maxillary sinus
floor shown in CBCT (d) and periapical radiography (h)
of any dental/periodontal pathology (Fig. 3). Finally, soft
tissue thickening of mixed origin was scored as a soft tissue
density mass within the sinuses, which was generalized and
with a potentially mixed dental and rhinogenic etiology.
Dome-shaped radiopacities in the maxillary sinus were
recorded and classified as mucosal retention cysts. These
were considered pathological entities of non-odontogenic
origin.
Two calibrated observers experienced in oral radiology
evaluated the CBCT and periapical radiographs. Calibra-
tion was done by reviewing, discussing and testing cases
for 2D and 3D scoring in the presence of a dentomaxillo-
facial radiology expert.
During the observational study, both observers reviewed
the scans independently on the same monitor and under equal
examining conditions in a dimmed room at 60 cm distance
from a diagnostic viewing screen. Images were observed
using the OnDemand viewing software (CyberMed, Seoul,
South Korea), with the 15 Accuitomo cases being initially
viewed with i-Dixel One Volume Viewer (J. Morita).
Image manipulation was done by changing contrast/
brightness levels, and magnification was permitted to
enhance visibility. In the event of discrepancies between
individual reviewers diagnosis, consensus was attempted
by re-evaluating the scans.
Statistical analysis was performed using PASW 18.0 for
Windows (SPSS, Chicago, IL, USA). Descriptive statistics
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Fig. 2 a Coronal and b panoramic reconstruction view of CBCT
images from Scanora 3D of a patient with apical periodontitis at
tooth 26 with tooth-associated soft tissue thickening
were performed. Results of diagnostic radiographic meth-
ods were reported in frequency tables for the anatomical
relationships, apical periodontitis and extension of apical
periodontitis to the sinus floor. Data obtained from both
imaging methods were compared statistically with McNe-
mar test. A p value of \0.05 was considered to indicate a
significant difference. The levels of inter- and intra-
observer agreement were assessed for the presence of
apical periodontitis using kappa statistics.
Results
Comparison of the anatomical relationship
between the maxillary teeth to the sinus floor in PA
radiographs and CBCT images
Five-hundred and thirty-seven maxillary teeth in 145 sub-
jects were classified according to PA and CBCT images. It
appeared from the CBCT observations that half of the 1st
and slightly fewer of the 2nd molars (45 %) were in inti-
mate relationship with the maxillary sinus (Fig. 4).
Although PA radiography showed satisfactory results in
the canine and premolar area, it was rather unreliable in the
2nd premolar and molar regions. For second premolars,
only 12 % of the roots had an intimate relationship with the
sinus floor and two-fifth of the roots were projecting
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Fig. 3 a Coronal and b panoramic reconstruction view of CBCT
images (Scanora 3D) of a patient with rhinogenic sinusitis
laterally in the sinus wall. There was an overestimation of
the number of anatomically related 1st molar teeth by
27 %. When PA radiography showed an intimate rela-
tionship with the maxillary sinus, only in 58 % of cases,
this relationship has been confirmed by CBCT, and all
other cases presented a lower classification and mostly in
close relationship with sinus floor. In the 2nd molar area,
there was an underestimation of an intimate relationship of
the roots with the sinus floor by 10 %. In 70 % of the cases,
this relationship was confirmed by CBCT. Figure 5 sum-
marizes the results of the intimate relationship between the
maxillary tooth and maxillary sinus floor in periapical
radiographs and CBCT images.
Apical periodontitis and extension to the sinus floor
From our sample group, 42 % of sinuses showed soft tissue
thickening in CBCT images. Tooth-related etiology
occurred in 67 % of the cases. The most likely cause of
odontogenic mucosal thickening was apical periodontitis
(88 %) followed by periodontal diseases (12 %).
When comparing CBCT and periapical images, nineteen
teeth had lesions detected by both modalities, whereas 31
teeth had lesions discernible only by CBCT and missed by
PA radiography. Overall results showed that the periapical
radiograph missed more than 60 % of the lesions. This
difference became significant in the molar region
(p = 0.00). Forty-two percent of these undetected lesions
were found in the first molar region (Fig. 6).
Odontology
Fig. 4 Bar chart showing the
percentage of different
anatomical relationships
between maxillary teeth and the
sinus floor as shown by CBCT
images
Fig. 5 Intimate relationship between maxillary posterior teeth found
in CBCT and PA radiography
A total of 36 teeth with apical infection extended to the
maxillary sinus were detected with CBCT, of which only 1
(2.7 %) was identified with PA radiography.
When comparing the inter-observer scores for assess-
ment of the periapical periodontitis, kappa ranged between
0.68 and 0.73 for PA and CBCT images, respectively. When
comparing the intra-observer scores, the kappa was between
0.80 and 0.89 for PA and CBCT imaging. It can be seen that
for the intra-and inter-observer comparisons, all kappa
values were found in the 0.610.80 (substantial agreement)
or 0.811 (almost perfect agreement) range [26].
Discussion
When comparing the results of CBCT and PA radiography,
it seems that PA images cannot provide the clinician with
Fig. 6 Results of periapical radiography and CBCT imaging for the
presence of apical periodontitis in maxillary posterior teeth
sufficient information regarding anatomical relationship
and pathology around the maxillary posterior teeth. CBCT
images showed an intimate relationship between the sinus
floor and the molar roots in approximately half of the cases.
The present study showed that PA radiography often failed
to predict the correct relationship of the roots with the
maxillary sinus.
While there was an overestimation of the intimate
relationship by 27 % in the 1st molar area, PA radiography
showed 10 % underestimation of an intimate relationship
of the roots with the sinus floor in the 2nd molar region.
The discrepancy between the observations made by
CBCT and PA radiography could be related to different
reasons. First of all, superimposition of anatomical struc-
tures in the molar region can decrease the visibility of the
region of interest. In addition, for multi-rooted teeth with
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divergent or convergent root anatomy, it is impossible to
completely eliminate some degree of geometric distortion.
Furthermore, a shallow palatal vault may also prevent an
ideal positioning of the intraoral image receptor even when
using a beam-aiming device [27]. All of these orientation
errors and overlapping problems can result in anatomical
masking, geometric distortion and magnification of the
radiographic image.
Quantitative results of the anatomical relationship
between the maxillary teeth and the sinus floor in the liter-
ature are somewhat conflicting [13, 2831]. However, most
of the studies emphasized that this close anatomical rela-
tionship may have clinical consequences with regard to
extraction or endodontic procedure [31, 32]. In our study, the
use of CBCT has clearly shown that in half of the first and
second molar teeth, at least one root was in direct contact
with the maxillary sinus. These findings emphasized that
every surgical and endodontic procedure in this area should
be performed with a full understanding of this anatomical
relationship to prevent any post-treatment complications.
Based on the design of our study, apical periodontitis
was the most likely odontogenic cause of soft tissue
thickening. Apical periodontitis from the 1st maxillary
molars was by far the largest contributor (42 %). This
finding is consistent with previous reports [24, 33, 34].
Diagnosis of periapical pathology is largely based on PA
radiographic examination. The findings of the present study
demonstrated that CBCT images tend to offer better scores
than PA radiographs, suggesting that diagnosis of apical
periodontitis with conventional images is frequently
underestimated, especially in the molar region (p = 0.00).
Fig. 7 Apical periodontitis in
the left 2nd molar, not easily
depicted in PA radiography (a),
but clearly visualized with
reactive soft tissue thickening
while viewing sagittal (b),
coronal (c) and axial (d) planes
of a CBCT scan
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Odontology
The small size of apical lesions, the overlap of three-rooted
maxillary molar teeth and the superimposition of anatom-
ical structures such as zygomatic process in periapical
radiography are likely to be the major factors for unde-
tected apical lesions. Even when acquiring PA radiographs
with the highest resolution and an optimal projection
technique, images lack the 3rd dimension [12]. Recently,
Low et al. [13] reported that the detection of periapical
lesions by PA radiography could be reduced when the root
apices were in close proximity to the floor of the maxillary
sinus and when there was \1 mm of bone between the
periapical lesion and the sinus floor.
In addition, it is well known that under certain condi-
tions, periapical lesions may not be seen in PA radiography
[35, 36]. The ability to detect an apical lesion radiograph-
ically depends not only on the size of the lesion but also to
trabecular or cortical involvement, X-ray angulations, and
location of periapical lesions [3537]. The periapical
lesions confined within the cancellous bone could be missed
in periapical radiography if cortical bone is intact [35, 36].
It should be mentioned that the present study was lim-
ited by the use of one periapical radiograph of the involved
tooth to identify apical lesions in the posterior maxilla. The
study had indeed a retrospective nature with recruitment of
consecutive cases having a CBCT scan apart from a peri-
apical radiograph in the posterior maxilla. A second peri-
apical radiograph, with an altered horizontal projection,
may be beneficial for diagnosis of multi-rooted teeth. Yet,
the limited field of view of periapical radiographs and the
anatomic overlap of the three-rooted teeth, the maxillary
sinus and the zygomatic process hamper full visualization.
Odontology
All those factors no longer play a role when using
CBCT. The three-dimensional image of the area could be a
significant advantage in diagnosis, especially when dealing
with multi-rooted teeth [38].
The difficulty to detect apical periodontitis in PA images
has been mentioned in several studies [1319]. The present
study also emphasized a high percentage of pre- or post-
treatment effects of apical periodontitis spotted in the
maxillary sinus, which may have been missed by PA
radiographs (Fig. 7). Although the finding of periapical
radiolucencies and soft tissue thickening may not neces-
sarily represent infected tissue and/or require treatment, the
proper identification may contribute to an improved diag-
nosis, also yielding a better prognostic evaluation of the
involved teeth. When PA radiographs fail to show pathol-
ogy, a CBCT examination can lead the clinician to identify
the patients underlying problems, resulting in a more
effective management of endodontic cases.
When we consider the cases with an intimate relationship
of the molar roots to the sinus floor, it is obvious that the
extension of apical periodontitis to the sinus floor seems
more probable. With regard to the ability of PA radiography
and CBCT to detect expansion of the lesion into the maxil-
lary sinus, CBCT evaluation was significantly more infor-
mative. In the present study, 36 cases of apical periodontitis
had a direct connection to the sinus floor without bony
coverage. The majority of them (75 %) were noted in 1st and
2nd molar teeth. Out of the 36 cases identified by CBCT, only
1 of these was identified by periapical radiography.
Despite the obvious advantages of CBCT imaging in
diagnosis, we should always bear in mind that CBCT uses
ionizing radiation and is not without risk. It is essential that
patient radiation exposure is kept as low as reasonably
possible. The effective dose of a periapical radiograph in
the molar region has been reported to be in the range of
15 lSv [3941] and the effective dose of CBCT imaging
was in range of 4654 lSv for Scanora or Accuitomo
CBCT devices [42].
The results of this study suggest that CBCT imaging of
the teeth and the surrounding bone may be of value in cases
of periapical periodontitis, especially in multi-rooted teeth.
Failure of PA radiography to diagnose periapical lesions
does not justify a routine use of CBCT examination.
Therefore, every case should be judged individually, and
this modality should be considered in selected cases, when
further detailed information is required for the diagnosis
and treatment planning.
Conclusion
The present study stresses that periapical radiography is not
always able to visualize pathology in the maxillary molar
area. In cases where CBCT imaging is available (even
when taken for other reasons), these image data may be
used for visualization of anatomy and diagnosis of
pathology in the posterior maxilla, especially in relation to
the first and second maxillary molar. Indeed, the present
study has clearly shown that in half of the first and second
molar teeth, at least one root was in direct contact with the
maxillary sinus. These findings emphasized that every
surgical and endodontic procedure in this area should be
performed with a full understanding of this anatomical
relationship to prevent any post-treatment complications.
The present study also emphasized that diagnosis of
apical periodontitis with conventional images is frequently
underestimated, with 60 % of the periapical pathologies
missed on PA radiographs. However, the higher radiation
dose emphasizes that CBCT should be used in selected
cases only, and after a thorough clinical examination and
justification.
Conflict of interest The authors declare that they have no conflict
of interest.
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