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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 329-336

Incidental findings in patients who underwent cone beam computed tomography for implant treatment planning


1 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Biruni University, Zip 34010, İstanbul, Turkey
2 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Akdeniz University, Dumlupinar Avenue, Zip 07058, Campus, Antalya, Turkey
3 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Aydın Adnan Menderes University, Aydın, Turkey
4 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Ataturk University, Zip 25340, Erzurum, Turkey

Date of Submission12-Jun-2019
Date of Acceptance28-Oct-2019
Date of Web Publication5-Mar-2020

Correspondence Address:
Asst. Prof. E Kurtuldu
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Biruni University, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_309_19

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   Abstract 


Objectives: The aim of this study is to determine the type, frequency, and location of incidental findings in the maxillofacial region in patients undergoing cone beam computed tomography (CBCT) scan for implant treatment.[5]Methods: In this study, 300 patients who underwent CBCT imaging for implant treatment planning were evaluated retrospectively. Patients were evaluated in four different categories, namely, maxillary sinus pathologies, temporomandibular joint (TMJ) findings, dentoalveolar findings, and soft-tissue calcifications. In maxillary sinus pathologies, we categorized patients by mucosal thickening, polypoidal lesion, air–liquid level, total opacification, oroantral fistula, periapical lesion related with maxillary sinus, antrolith, hypoplasia, and foreign body presence. In the TMJ findings category, we evaluated patients for erosion, osteophyte, sclerosis, flattening, and bifid condyle. For dentoalveolar findings, we looked for the residual root and impacted tooth. In soft-tissue calcifications, we examined patients for tonsillolith, sialolith, lymph node calcification, styloid ligament calcification, carotid artery calcifications, and osteoma cutis. Results: Mucosal thickening was mostly seen in maxillary sinus pathology. One hundred and forty-eight (49.3%) of the patients had at least one TMJ incidental finding. We detected at least one impacted tooth in 17 (5.7%) patients' maxilla and 14 (4.7%) patients' mandibles. The most frequently seen calcification was styloid ligament calcification. There was no statistically significant relationship between the age groups and incidental findings (P > 0.05). Conclusions: Oral radiologists should be aware of incidental findings and evaluate the possibilities of underlying diseases in a comprehensive way, and if there is a concern about the finding, they should refer the patient to the relevant specialist.

Keywords: Cone beam computed tomography, incidental finding, maxillary sinus, temporomandibular joint


How to cite this article:
Kurtuldu E, Alkis H T, Yesiltepe S, Sumbullu M A. Incidental findings in patients who underwent cone beam computed tomography for implant treatment planning. Niger J Clin Pract 2020;23:329-36

How to cite this URL:
Kurtuldu E, Alkis H T, Yesiltepe S, Sumbullu M A. Incidental findings in patients who underwent cone beam computed tomography for implant treatment planning. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 2];23:329-36. Available from: http://www.njcponline.com/text.asp?2020/23/3/329/280027




   Introduction Top


Cone beam computerized tomography (CBCT) is an important diagnostic imaging modality that is commonly used in the maxillofacial region, providing excellent images of high-contrast structures, such as maxillofacial bone anatomy and teeth.[1] In dentistry, CBCT is used to evaluate impacted and supernumerary teeth, edentulism, endodontic lesions, pathologies, infections, and deformities. At the same time, it can provide detailed information about anatomical structures, such as the temporomandibular joint (TMJ), skull base, paranasal sinuses, vertebras, and pharyngeal airways.[2] As imaging techniques develop, the ability to determine incidental findings increases and findings from anatomical variations to malignant lesions, which are not related to the area to be examined, can be identified. Failure to provide follow-up and treatment for incidental findings may have negative consequences for the patient and may cause dentists to neglect their legal responsibilities.[3] For this reason, peripheral structures appearing in the imaging field should be taken note of and all structures should be evaluated to avoid any missing findings. A better understanding of incidental findings and the head–neck anatomy will enable clinicians to avoid misinterpretations.[4],[5]

The aim of this study is to determine the type, frequency, and location of incidental findings in the maxillofacial region in patients undergoing CBCT for implant treatment.


   Material and Method Top


Study design

In this study, 300 patients (152 female and 148 male) who underwent CBCT imaging for implant treatment planning between 2017 and 2018 were evaluated retrospectively. These patients, who were randomly chosen, had not previously undergone surgical treatment for a tumor or cyst nor had they previously undergone orthognathic or implant surgery. The patients' ages ranged between 18 and 74 years, and the mean age was 46.73 years. Patients were divided into six age groups, including 18–29, 30–39, 40–49, 50–59, 60–69, and 70–79 years of age.

This study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2008 and the Atatürk University Faculty of Dentistry Ethics Committee approved the protocol. (project identification code: 19/06).

Imaging method and analysis

All the CBCT images were performed in the Atatürk University Faculty of Dentistry, Department of Dentomaxillofacial Radiology, and the imaging was performed using a NewTom 3G (Quantitative Radiology, Verona, Italy), which has a maximum output of 110 kVp and 15 mA, a 0.16-mm3 voxel size, an approximate 5.4s exposure time, and a 14 cm × 17 cm field of view.

Patients were selected randomly. All the images were examined on 0.5 mm axial, coronal, and sagittal plane, and the cross-sectional images were examined with an NNT viewer software program in multiplanar reconstructions mode. The CBCT examinations were conducted by an observer with at least 3 years of experience in CBCT imaging. One month after the first examination to reduce errors, 100 CBCT images were chosen randomly and reevaluated for the intraobserver reliability.

In this study, patients were evaluated in four different categories, which are maxillary sinus pathologies, TMJ findings, dentoalveolar findings, and soft-tissue calcifications. In maxillary sinus pathologies, we categorized the patients by mucosal thickening, polypoidal lesion, air–liquid level, total opacification, oroantral fistula, periapical lesion related with maxillary sinus, antrolith, hypoplasia, and presence of any foreign body. In the TMJ category, we evaluated patients for erosion, osteophyte, sclerosis, flattening, and the bifid condyle. For dentoalveolar findings, we looked for the residual root and impacted teeth. In soft-tissue calcifications, we examined patients for tonsillolith, sialolith, lymph node calcification, styloid ligament calcification, carotid artery calcifications, and osteoma cutis.

Statistical analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program (SPSS v. 20.0 for Windows, Chicago, IL). The descriptive analyses and frequencies were calculated for age, gender, dental status, and incidental findings. A Chi-square test was performed to explore the relationships between qualitative variables and gender or age groups. The intraobserver agreements were assessed by kappa (κ) coefficients.


   Results Top


The 300 CBCT scans were performed on 152 (50.7%) female and 148 (49.3%) male patients, whose mean age was 46.73 years (ranging between 18 and 74 years). The κ coefficient was above 0.85 in all parameters.

The most frequent incidental findings of this study were maxillary sinus pathologies. [Table 1] shows maxillary sinus pathologies that were observed in the scans and those pathologies were categorized into nine groups. One hundred and nine (36.3%) patients did not have any pathologies for both sides of the maxillary sinuses. Eighty-nine (29.6%) patients did not have any pathologies in only one of their maxillary sinus. Mucosal thickening was the most frequently seen maxillary sinus pathology and polypoidal lesions were next in frequency [Figure 1]. There was no statistical age or gender difference found among maxillary sinus pathologies (P > 0.05).
Table 1: Maxillary sinus pathologies of 300 patients

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Figure 1: CBCT coronal images of a. Bilateral maxillary sinuses without any pathologies. b. Bilateral maxillary sinuses with a mucosal thickening. c. Right maxillary sinus with the polypoidal lesion d. Right maxillary sinus showing hypoplasia. e. Foreign body in the right maxillary sinus. f. Bilateral maxillary sinuses showing antrolith

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On the CBCT images, the TMJ cortical bone changes were evaluated and findings ranked as erosion, osteophyte, sclerosis, and flattening [Figure 2]. One hundred and forty-eight (49.3%) patients had at least one TMJ incidental findings in one or both of their temporomandibular condyles. Those changes were found in different combinations. The most frequently seen TMJ findings were a combination of erosion and osteophyte formation. For the left side of the TMJ, 10.7% of the population and for the right side of the TMJ 9.7% were found to have an erosion and osteophyte combination. There was no statistical correlation or difference found between gender and TMJ pathologies [Table 2] (P > 0.05).
Figure 2: CBCT cross-sectional images of a. Normal mandibular condyle without any cortical bone changes. b. Mandibular condyle with erosion. c. Bifid mandibular condyle. d. Mandibular condyle with osteophyte formation

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Table 2: TMJ findings of the patients

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The patients had different dental status because of missing teeth in the mouth. We categorized the patients in four different groups. [Table 3] shows the dental status of patients. [Table 4] shows the dentoalveolar findings of the patients. On the CBCT images, for dentoalveolar incidental findings, we evaluated for impacted teeth and residual roots. The left maxillary third molar tooth was the most frequently seen impacted tooth in the maxilla, and the mandible right and left third molar teeth were the most frequently seen impacted teeth in the mandible. There was no statistical age or gender difference found among those with the impacted teeth or residual roots.
Table 3: Dental status of the patients.

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Table 4: Dentoalveolar findings of the patients

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Soft-tissue calcification characteristics evaluated in our population are given in [Table 5]. We evaluated six different calcifications, namely, tonsillolith, carotid artery calcification, styloid ligament calcification, sialolith, lymph node calcification, and osteoma cutis [Figure 3] and [Figure 4]. The most frequently seen calcification was styloid ligament calcification and the second most common was tonsillolith. There was no statistically significant relationship between age groups and soft-tissue calcifications (P > 0.05).
Table 5: Characteristics of soft.tissue calcifications that were observed in 300 patients

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Figure 3: CBCT axial images of a. Osteoma cutis on both sides of the face. b. Tonsillolith on the left side. c. Carotid artery calcification on the left side

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Figure 4: CBCT panoramic reconstruction of bilateral styloid ligament calcification

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   Discussion Top


Due to the limitations of two-dimensional imaging methods, some pathologies, calcifications, or anatomical variations may be missed.[2] Asymptomatic or occult pathologies can cause delayed diagnosis, which may negatively affect possible treatment plans and outcomes. Early diagnosis and improved diagnostic accuracy are necessary to improve patient care and treatment and reduce treatment time, complications, and costs. As CBCT examinations provide more information than the two-dimensional methods, radiologists are expected to detect a higher rate of incidental findings using this method. There are many studies on CBCT related to incidental findings which are including localized findings of maxillary sinuses, dentition, TMJ, and systemic diseases,[1],[2],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] some of them conducted in specific patient groups.[7],[9],[10],[12],[13],[14],[16] This study recorded incidental findings in CBCT in a group of patients who underwent CBCT imaging for implant treatment planning. To our knowledge, only Mutalik et al.[17] and Pette et al.[13] have conducted studies of incidental findings in patients who underwent CBCT for implant treatment planning. While Mutalik et al.'s study is quite different from our study, there are some similarities between our study and the Pette et al. study.

Researchers found the frequency of incidental findings different. This variability may depend on the differences in sample sizes, age group differences, the categorization of incidental findings, and the size of the FOV field.[2],[6],[8],[10],[11],[12],[15],[18]

The most common incidental finding of the current study showed in the maxillary sinuses (49.8%). Incidental findings of maxillary sinuses had the first or second highest rate of incidental findings in the literature.[1],[6],[8],[11],[15] The most common incidental finding in the maxillary sinus was mucosal thickening (29.8%), which is similar to other studies.[8],[12],[15],[19],[20] The normal thickness of the maxillary sinus mucosa is 0.8–1 mm, and with no consensus about how thick the mucosa should be for mucosal thickening in the literature. The maxillary sinus mucosa thickness value varies between 2-6 mm for the diagnosis of 'mucosal thickening'.[21],[22] This cutoff value was accepted as 1 mm by Pazera et al.[12] and 2 mm by Lopes et al.[11] and Sanches Perez et al.[20] Following Lana et al., the current study accepted a value of 3 mm.[19] Variability in the rate of mucosal thickness may be because the researchers accepted different threshold values and the patient criteria included in the study were different.

The mucous retention cyst and antrochoanal polyp represent polypoid lesions of the maxillary sinus. The first lesion is a common asymptomatic incidental finding that can be viewed at 2%–5% rate on radiographic examinations.[19] It is characterized by a dome-shaped radiopacity, extending from the sinus wall. The second lesion is a benign polypoid lesion that originates from the maxillary sinus mucosa and extends through its ostium to the choana.[19],[20] As both polypoid lesions show fluid density in the sinus on CT, they cannot be differentiated only with CT findings.[19],[20],[23] For that reason, both have been grouped under the same heading in the current study, following Sanchez Perez et al.,[20] Lana et al.,[19] Drage et al.,[7] and Pazera et al.[12] On the other hand, in their study, Price et al.[1] separated polypoid lesions into mucosal retention cysts and antral polyps. Drage et al.[7] found the rate of incidence of polypoidal lesions to be 7.9% rate, while Perez et al.,[20] Pazera et al.,[12] and Lana et al.[19] found it to be 13.75%, 19.4%, and 21.4%, respectively. Avsever et al.[15] found this rate to be 14.3% in the right maxilla and 13.7% in the left maxilla. The current study's results showed this rate to be 11.8%. Maxillary sinus hypoplasia is maxillary sinus underdevelopment in the embryological period or late period because of trauma, structural, or iatrogenic causes.[19],[24] While the rate of maxillary sinus hypoplasia was found to be 2.2% at the current study, Lana et al.,[19] Avsever et al.,[15] and Allaready et al.[2] found this rate to be 4.8%, 2.3%, and 2.1%, respectively. Antroliths are pathologic calcifications formed as a result of mineral salt deposition in the paranasal sinuses and show up as radiopaque masses with different sizes and shapes in the radiographic examination.[19],[23],[25] Antrolith incidence was between 0.15%–4.54% in literature.[1],[7],[19],[21],[23] This incidence was 1.3% in the current study and our results were in accordance with other studies. Oroantral fistula is a common complication of dental surgery.[1] Surgical treatment should be done so that normal sinus function can resume and inflamed sinus mucosa can heal.[1],[26] While Rege et al.[21] found the incidence of oroantral fistula rate to be 2.2%, Price et al.[1] found it to be 2.7% in their study, and nine of these cases involved implant patients. The current study examined patients who underwent CBCT imaging for implant treatment and we found oroantral fistula percentage as 0.3%. This result is quite lower than in the aforementioned research. Foreign bodies may access the maxillary sinus via an oroantral fistula.[19],[20] This can also occur through tooth extraction or root canal treatment (RCT) or because of surgical procedures in the maxillary sinus.[19] While the current study found foreign bodies in the maxillary sinus at a rate of 0.3%, Sanchez Perez et al.[20] and Lana et al.[19] found this rate to be 6.88% and 1.6%, respectively.

The second (40.4%) most common incidental finding occurred in the TMJ findings of the current study. Degenerative diseases of the TMJ diagnosed with radiography may be an incidental finding. On the other hand, clinical symptoms and patient anamnesis are important for understanding disease activity. TMJ condyle erosion is defined as an area of the decreased density of the cortical bone and adjacent subcortical bone.[27] Drage et al.,[7] Caglayan and Tozoglu,[8] and Price et al.[1] found the TMJ condyle erosion incidence rate to be 1.2%, 4.8%, and 11.33%, respectively. In the current study, we found TMJ condyle erosion in 177 TMJ (29.5%). This rate was quite higher than in the research mentioned. Osteophyte is marginal bony outgrowths on the condyle.[27] Osteophyte incidence was between 3.4% and 11.11% in the literature.[1],[8],[11],[14] In the current study, we found this rate to be 21.3% in 128 TMJs. Areas of increased density of the cortical bone extending to bone marrow are called sclerosis.[27] Among the reference studies, only Price et al.[1] (3.3%) examined the TMJ subchondral sclerosis. The incidence of TMJ subchondral sclerosis in this study was lower (7.5%) than in the current study. TMJ condyle flattening is the loss of convexity of the condyle shape and a signal of a remodeled bone or physiological response to an increase of load.[11] TMJ condyle flattening incidence is between 2.5% and 16.7% among the reference studies.[1],[7],[10],[11],[14] In the current study, we found this rate to be 7.7%. This result was in accordance with other studies. The bifid condyle is a rare anomaly and its etiology is not clear. It may be a developmental anomaly or have a traumatic origin and no treatment is needed.[11] In the current study, the incidence of the bifid condyle (4.3%) is higher than in other studies.[1],[7],[8],[10],[11],[14]

In the current study, the presence of impacted teeth and residual roots were evaluated as incidental findings, except for the above-mentioned parameters. While the rate of impacted teeth was 4.7% in the mandible and 5.7% in the maxilla, the residual root rate was 7.7% in the mandible and 13% in the maxilla. Caglayan and Tozoglu[8] found the incidence of impacted teeth to be 21.7%, and this result was the second most common incidental findings in their study. On the other hand, while Lopes et al.[11] found this incidence to be 1.33% in the maxilla field of view and 16.94% in the maxilla/mandibular field of view, Rheem et al.[10] found this rate to be 6.12%. Among the reference studies, only Lopes et al.[11] examined the residual root (0.89% in the maxilla field of view, 4.04% in the mandible field of view, and 0.89% in the maxilla/mandible field of view). The incidence of the residual root in this study was lower than the current study in both maxilla and mandible.

Soft-tissue calcifications are common in the oral and maxillofacial region. They are most often detected as incidental findings during routine radiographic examination.[28] Soft-tissue calcifications can be pathological, age-related, or idiopathic.[1] Some of them may be serious and require treatment or follow-up.[28] Soft-tissue calcifications are much more common among older people.[3] Lopes et al.[11] found that there was a statistically significant difference in which the older the patient was, the greater were the number of calcifications. Pette et al.[13] found that atheroma was 13.4 times more common in patients above 65 years of age. In the current study, there was no statistically significant relationship between the age groups and soft-tissue calcifications (P > 0.05).

Tonsilloliths are present in the tonsils and can be multiple or single. While they are usually asymptomatic and do not need treatment, the larger ones can cause problems, such as sore throat, halitosis, foreign body sensation, or dysphagia, and require medical treatment.[1],[11] The incidence of tonsilloliths is between 0.43%–14.3% among the reference studies.[1],[2],[11],[13] In this study, the incidence was 17.7%, which is higher than in the reference studies. Carotid artery calcifications could be an indicator of metabolic disease or potential stroke. They are radiographic evidence of atherosclerosis.[1] The patients who have carotid artery calcifications should be referred for further investigation. While Allareddy et al.,[2] Price et al.,[1] and Rheem et al.[10] found the incidence of carotid artery calcifications to be 5.7%, 4.3%, and 2.04%, respectively, the incidence was found to be 2.8% in the current study, a result that was similar to the other studies. Styloid ligament calcification is a long, thin, asymptomatic, and sharp radiopaque tissue extending downward from the styloid process and occurs bilaterally or unilaterally. As in the literature, for styloid ligament calcification, we considered the cases above 3 cm in length. Styloid ligament calcification incidence is between 3.1% and 26.7% among the reference studies.[1],[10],[11],[13] In the current study, the incidences of stylohyoid ligament calcification were 22.7%, and while it was lower than Price et al.,[1] it was higher than Pette et al.,[13] Lopes et al.,[11] and Rheem et al.[10] Sialolith is mineral salt deposition in the salivary glands or their ducts and may be asymptomatic or on occasion show pain and swelling.[1] According to the literature, its incidence is low and between 0.4% and 1.1%.[1],[2],[13],[14] The current study showed this rate to be 1.3%. Calcification foci occur over time in the lymph nodes, which expand because of inflammation. Radiographically calcified lymph nodes are seen in the cauliflower view.[28] There are no studies investigating the frequency of calcified lymph nodes among the reference studies. The incidence of calcified lymph nodes in the current study is 0.7%. Osteoma cutis is usually associated with chronic acne or dermatosis scars, and it is a rare, soft-tissue calcification in the skin and maybe diagnosed incidentally with radiographic examination.[28] Among the studies, just Allareddy et al.[2] investigated osteoma cutis incidence and found the rate as 2.3%. This rate is similar to that in the current study (2.7%).

The current study has several limitations. First, similar to other studies in the literature, it is a cross-sectional study. The main disadvantage of such a study is that the data analyzed are restricted to the available information. On the other hand, misdiagnoses and misinterpretations in this type of study are also known to be equally distributed.[29] Another limitation of this study is that a single observer evaluated the data. However, intraobserver reliability was high.


   Conclusion Top


Within the limitations of this study, TMJ incidental findings were generally higher than in the reference studies. There was no statistically significant relationship between the age groups and soft-tissue calcifications. Oral radiologists should be aware of incidental findings and must evaluate the possibilities of underlying diseases in a comprehensive way, and if there is a concern about the finding, they should refer the patient to the relevant specialist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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