Detection and measurements of apical lesions in the upper jaw by cone beam computed tomography and panoramic radiography as a function of cortical bone thickness

  • Ali-Reza KetabiEmail author
  • Sandra Ketabi
  • Mohamed Badis Nabli
  • Hans-Christoph Lauer
  • Martin Brenner
Original Article



In the current literature, cone beam computed tomography (CBCT) seems to be more accurate in detecting apical lesions (AL) than two-dimensional radiographs. Cortical bone thickness might have an influence on AL visibility. Therefore, the purpose of the study was to directly compare the diagnostic accuracy of panoramic radiography (PANO) and CBCT in detecting AL in the upper jaw and determine the influence of cortical bone thickness on AL visibility.

Materials and methods

Anonymised digital images of 351 patients who received a CBCT image and a panoramic radiograph within 90 days were examined for AL in the upper jaw. The analysis was conducted by a trained examiner and reviewed by an expert in dental radiology. Further, the dimensions of AL and cortical bone thickness in the region affected by AL were measured to determine their influence on visibility. Statistical analysis was carried out by means of statistical software (IBM SPSS 25; Armonk, NY, USA).


The mean age of the patients was 58.9 years with an almost equal gender distribution. A total of 2223 teeth in the upper jaw were included in the final analysis. CBCT detected AL on 144 teeth (6.5%), of which only 23 were also visible on a PANO. The difference between both methods was significant (p < 0.001). The dimensions of AL measured within a PANO were approximately twice as high as those measured by CBCT. However, the difference was not significant (p ≥ 0.005). Cortical bone thickness had no influence on AL visibility.

Conclusions and clinical relevance

Panoramic radiographs are unsuitable for a reliable diagnosis of AL in the upper jaw, while CBCT leads to a better visualisation of AL. Bone thickness has no significant influence on AL visibility with either imaging method.


Apical lesions Cone beam computed tomography Panoramic radiography Cortical bone thickness Visibility 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval of this study was sought and granted by the Medical Council of Baden-Württemberg, Germany (registration no. F-2014-006-z). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Campello AF, Goncalves LS, Guedes FR, Marques FV (2017) Cone-beam computed tomography versus digital periapical radiography in the detection of artificially created periapical lesions: a pilot study of the diagnostic accuracy of endodontists using both techniques. Imaging Sci Dent 47:25–31. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR (2008) Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod 34:273–279. CrossRefPubMedGoogle Scholar
  3. 3.
    European Society of Endodontology (2006) Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J 39:921–930CrossRefGoogle Scholar
  4. 4.
    Patel S, Dawood A, Whaites E, Pitt Ford T (2009) New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems. Int Endod J 42:447–462. CrossRefPubMedGoogle Scholar
  5. 5.
    Nair MK, Nair UP (2007) Digital and advanced imaging in endodontics: a review. J Endod 33:1–6. CrossRefPubMedGoogle Scholar
  6. 6.
    Peters CI, Peters OA (2012) Cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. Endod Top 34:57–75CrossRefGoogle Scholar
  7. 7.
    Folk RB, Thorpe JR, McClanahan SB, Johnson JD, Strother JM (2005) Comparison of two different direct digital radiography systems for the ability to detect artificially prepared periapical lesions. J Endod 31:304–306CrossRefPubMedGoogle Scholar
  8. 8.
    Hadley DL, Replogle KJ, Kirkam JC, Best AM (2008) A comparison of five radiographic systems to D-speed film in the detection of artificial bone lesions. J Endod 34:1111–1114. CrossRefPubMedGoogle Scholar
  9. 9.
    White SC, Atchison KA, Hewlett ER, Flack VF (1995) Efficacy of FDA guidelines for prescribing radiographs to detect dental and intraosseous conditions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:108–114CrossRefPubMedGoogle Scholar
  10. 10.
    van der Stelt PF (1985) Experimentally produced bone lesions. Oral Surg Oral Med Oral Pathol 59:306–312CrossRefPubMedGoogle Scholar
  11. 11.
    Huumonen S, Ørstavik D (2002) Radiological aspects of apical periodontitis. 2002(1):3–25Google Scholar
  12. 12.
    Kanagasingam S, Lim CX, Yong CP, Mannocci F, Patel S (2017) Diagnostic accuracy of periapical radiography and cone beam computed tomography in detecting apical periodontitis using histopathological findings as a reference standard. Int Endod J 50:417–426. CrossRefPubMedGoogle Scholar
  13. 13.
    Van Assche N, Jacobs R, Coucke W, van Steenberghe D, Quirynen M (2009) Radiographic detection of artificial intra-bony defects in the edentulous area. Clin Oral Implants Res 20:273–279. CrossRefPubMedGoogle Scholar
  14. 14.
    Halse A, Molven O, Fristad I (2002) Diagnosing periapical lesions--disagreement and borderline cases. Int Endod J 35:703–709CrossRefPubMedGoogle Scholar
  15. 15.
    Chanani A, Adhikari HD (2017) Reliability of cone beam computed tomography as a biopsy-independent tool in differential diagnosis of periapical cysts and granulomas: an in vivo study. J Conserv Dent 20:326–331. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kruse C, Spin-Neto R, Reibel J, Wenzel A, Kirkevang LL (2017) Diagnostic validity of periapical radiography and CBCT for assessing periapical lesions that persist after endodontic surgery. Dentomaxillofac Radiol 46:20170210. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Nascimento EHL, Oenning ACC, Freire BB, Gaeta-Araujo H, Haiter-Neto F, Freitas DQ (2018) Comparison of panoramic radiography and cone beam CT in the assessment of juxta-apical radiolucency. Dentomaxillofac Radiol 47:20170198. CrossRefPubMedGoogle Scholar
  18. 18.
    Torabinejad M, Rice DD, Maktabi O, Oyoyo U, Abramovitch K (2018) Prevalence and size of periapical radiolucencies using cone-beam computed tomography in teeth without apparent intraoral radiographic lesions: a new periapical index with a clinical recommendation. J Endod 44:389–394. CrossRefPubMedGoogle Scholar
  19. 19.
    Van der Veken D, Curvers F, Fieuws S, Lambrechts P (2017) Prevalence of apical periodontitis and root filled teeth in a Belgian subpopulation found on CBCT images. Int Endod J 50:317–329. CrossRefPubMedGoogle Scholar
  20. 20.
    de Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR (2009) Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold standard. J Endod 35:1009–1012. CrossRefPubMedGoogle Scholar
  21. 21.
    World Medical Association (2013) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 310:2191–2194. CrossRefGoogle Scholar
  22. 22.
    Patel S, Wilson R, Dawood A, Foschi F, Mannocci F (2012) The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography - part 2: a 1-year post-treatment follow-up. Int Endod J 45:711–723. CrossRefPubMedGoogle Scholar
  23. 23.
    Patel S, Wilson R, Dawood A, Mannocci F (2012) The detection of periapical pathosis using periapical radiography and cone beam computed tomography - part 1: pre-operative status. Int Endod J 45:702–710. CrossRefPubMedGoogle Scholar
  24. 24.
    Davies A, Mannocci F, Mitchell P, Andiappan M, Patel S (2015) The detection of periapical pathoses in root filled teeth using single and parallax periapical radiographs versus cone beam computed tomography - a clinical study. Int Endod J 48:582–592. CrossRefPubMedGoogle Scholar
  25. 25.
    Davies A, Patel S, Foschi F, Andiappan M, Mitchell PJ, Mannocci F (2016) The detection of periapical pathoses using digital periapical radiography and cone beam computed tomography in endodontically retreated teeth - part 2: a 1 year post-treatment follow-up. Int Endod J 49:623–635. CrossRefPubMedGoogle Scholar
  26. 26.
    Walter SD, Macaskill P, Lord SJ, Irwig L (2012) Effect of dependent errors in the assessment of diagnostic or screening test accuracy when the reference standard is imperfect. Stat Med 31:1129–1138. CrossRefPubMedGoogle Scholar
  27. 27.
    Pope O, Sathorn C, Parashos P (2014) A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 40:360–365. CrossRefPubMedGoogle Scholar
  28. 28.
    Leonardi Dutra K, Haas L, Porporatti AL, Flores-Mir C, Nascimento Santos J, Mezzomo LA, Correa M, De Luca Canto G (2016) Diagnostic accuracy of cone-beam computed tomography and conventional radiography on apical periodontitis: a systematic review and meta-analysis. J Endod 42:356–364. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Private Dental OfficeStuttgartGermany
  2. 2.DentavitaMannheimGermany
  3. 3.Department of Prosthodontics, Center for Dentistry and Oral Medicine (Carolinum)Johann Wolfgang Goethe-UniversityFrankfurtGermany

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