Introduction
Two-dimensional (2D) imaging modalities have been used in dentistry since the first intraoral radiograph was obtained in 1896. Since then, significant advances have been made in dental imaging techniques, including the introduction of panoramic imaging techniques and tomography. Advances in digital imaging techniques have led to lower radiation doses and faster processing times without changing the imaging geometry of these intraoral and panoramic technologies. Cone-beam computed tomography (CBCT) is a new medical imaging technique that generates three-dimensional (3D) data at lower cost and lower absorbed doses than conventional computed tomography (CT). The CBCT imaging technique is based on a cone-shaped X-ray beam that is centred on a 2D detector, and the beam performs one rotation around the object, producing a series of 2D images. The images are reconstructed in a 3D data set using a modification of the original cone-beam algorithm developed by Feldkamp et al. in 1984. CBCT images from the craniofacial region are often acquired at a higher resolution than conventional CT. In addition, these systems are more compact than conventional CT systems, which make them more practical for use in dental offices[1]. Increased access to such technology has led to CBCT scanners now finding many uses in dentistry especially in the fields of Implant Dentistry, Endodontics and Orthodontics. The application of CBCT imaging in different dental disciplines can guide diagnosis, treatment and follow-up.
This article presents a systematic review of clinical applications of CBCT in dental practice.

Review
Applications In Oral And Maxillofacial Surgery
CBCT in OMFS has been used to investigate the exact location of jaw pathology[2],[3],[4],[5],[6],[7] in 3D image , to assess impacted teeth , to assess supernumerary teeth and their relation to vital structures[3],[8],[9],[10],[11],[12],[13],[14],[15],[16] to evaluate changes in the cortical and trabecular bone related to bisphosphonate-asociated osteonecrosis of the jaws[17], and to assess bone grafts[18]. CBCT has also been used to investigate paranasal sinuses[3] and to assess obstructive sleep apnea.[19]
Because CBCT images are collected as a combination of several 2D slices, the technique is superior in overcoming superimpositions and calculating surface distances[20]. This advantage has made CBCT the technique of choice for the investigation of mid-facial fractures[5], [21] orbital fracture assessment and management[22], and in inter-operative visualization of the facial bones after fracture[23]. CBCT is largely used in planning orthognathic and facial orthomorphic surgeries[24], [25] which require detailed visualization of the interocclusal relationship to augment the 3D virtual skull model with a detailed representation of the dental surface. With the aid of advanced software, CBCT facilitates the visualization of soft tissue to allow for control of the post-treatment aesthetics) and permits the evaluation of lip and palate bony depressions in cases of cleft palate[26]. The ability of CBCT to detect salivary-gland defects is also under investigation[27]. In addition, one article has reported a tooth autotransplant case where CBCT demonstrated high accuracy, and the information provided allowed the rapid completion of the transplant operation[28].

Endodontics
CBCT is a very useful tool in diagnosing apical lesions.[12],[15],[17],[18],[29],[30],[31],[32],[33]. A number of studies have demonstrated its ability to enable a differential diagnosis of apical lesions by measuring the density from the contrasted images of these lesions, in whether the lesion is an apical granuloma or an apical cyst. [17], [32], [33]. Cotton et al.[12] used CBCT as a tool to assess whether the lesion was of endodontic or non-endodontic origin. CBCT also demonstrated superiority to 2-D radiographs in detecting fractured roots. Vertical and horizontal root fracture detection is described in several clinical cases.[12],[35],[36] It is also agreed that CBCT is superior to peri-apical radiographs in detecting these fractures, whether they are bucco-lingual or mesiodistal.[37],[38] In cases with inflammatory root resorption, lesions are detected much easier in early stages with CBCT compared to conventional 2-D X-ray.[18]. In other cases, such as external root resorption, external cervical and internal resorption, not only the presence of resorption was detected, but also the extent of it. [12], [33],[39]
CBCT can also be used to determine root morphology, the number of roots, canals and accessory canals, as well as to establishing the working length and angulations of roots and canals.[12],[32],[33],[35],[40] It also is accurate in assessing root-canal fillings.[32],[33],[41] Owing to its accuracy, it is very helpful in detecting the pulpal extensions in talon cusps and the position of fractured instruments.[42]
It is also a reliable tool for presurgical assessment of the proximity of the tooth to adjacent vital structures, size and extent of lesions, as well as the anatomy and morphology of roots with very accurate measurements.[12], [32], [33], [34], [35]
Additionally, in cases in which teeth are assessed after trauma and in emergency cases, its application can be a useful aid in reaching a proper diagnosis and treatment approach.[12],[32] Recently, owing to its reliability and accuracy, CBCT has also been used to evaluate the canal preparation in different instrumentation techniques. [43],[44]

Implantology
With increased demand for replacing missing teeth with dental implants, accurate measurements are needed to avoid damage to vital structures. This was achievable with conventional CT. However, with CBCT giving more ac curate measurements at lower dosages, it is the preferred option in implant dentistry today. [16],[45],[46],[47],[48],[49],[50],[51],[52],[53]. The advantages of CBCT in visualizing the alveolus in 3 dimensions and making precise measurements before surgery are obvious in the field of implant dentistry. With new software that constructs surgical guides, damage is also reduced further.[2],[16],[54],[55]. Heiland et al.[56] describe a technique in which CBCT was used inter-operatively in two cases to navigate the implant insertion following microsurgical bone transfer.
CBCT enables the assessment of bone quality and bone quantity.[2],[45],[46],[47] ,[51],[57],[58] This gives the surgeon the ability to anticipate implant placement and even to place implants in a virtual model in terms of bone height, bone width, nerve position and even objective measures of bone quality. This leads to reduced implant failure, as case selection can be based on much more reliable information. This advantage is also used for post-treatment evaluation and to assess the success of bone grafts [50].

Orthodontics
Orthodontists can use CBCT images in orthodontic assessment and cephalometric analysis.[46],[49] Today, CBCT is already the tool of choice in the assessment of facial growth, age, airway function and disturbances in tooth eruption.[59],[60],[61] CBCT is a reliable tool in the assessment of the proximity to vital structures that may interfere with orthodontic treatment.[62] In cases in which mini-screw implants are placed to serve as a temporary anchorage, CBCT is useful for ensuring a safe insertion [63],[64] and to assess the bone density before, during and after treatment . As the images are self-corrected from the magnification to produce orthogonal images with 1:1 ratio, higher accuracy is ensured. CBCT is thus considered a better option for the clinician.113

Orthognathic Surgery
Clinicians have long evaluated the usefulness of 3- dimensional imaging in orthodontics and orthognathic surgery, with a major concern being the correlation between soft tissue and hard tissue changes. Lateral cephalography has been the standard modality for diagnosing skeletal and dental deformities, as well as for use in surgical prediction and treatment planning. As useful as cephalometric analysis can be, its imaging accuracy is inadequate in such deformities as hemifacial microsomia, severe facial asymmetries and occlusal cant. Three-dimensional imaging of the hard and soft tissue makes all of the data available, the clinicians have to understand how best to apply and manipulate that data for more accurate surgery and treatment planning.

Temporomandibular joint disorder
One of the major advantages of CBCT is its ability to define the true position of the condyle in the fossa, which often reveals possible dislocation of the disk in the joint, and the extent of translation of the condyle in the fossa.[50],[33],[66] With its accuracy, measurements of the roof of the glenoid fossa can be done easily.[67] Another advantage of some of the available devices is their ability to visualise soft tissue around the TMJ, which may reduce the need for magnetic resonance imaging in these cases.[68] Owing to these advantages, CBCT is the imaging device of choice in cases of trauma, pain, dysfunction, fibro-osseous ankylosis and in detecting condylar cortical erosion and cysts.[46],[68]. With the use of the 3-D features, the image guided puncture technique, which is a treatment modality for TMJ disk adhesion, can safely be performed.[70]

Periodontics
CBCT can be used in assessing a detailed morphologic description of the bone because it has proved to be accurate with only minimal error margins. The measurements proved to be as accurate as direct measurements with a periodontal probe.[33],[71],[72] Furthermore, it also aids in assessing furcation involvements.[33]
CBCT can be used to detect buccal and lingual defects, which was previously not possible with conventional 2-D radiographs.[33],[73] Additionally, owing to the high accuracy of CBCT measurements, intra-bony defects can accurately be measured and dehiscence, fenestration defects and periodontal cysts assessed.[7],[33],[74] CBCT has also proved its superiority in evaluating the outcome of regenerative periodontal therapy.[73]

Operative Dentistry
Based on the available literature, CBCT is not justified for use in detecting occlusal caries, since the dose is much higher than conventional radiographs with no additional information gained. However, it proved to be useful in assessing proximal caries and its depth. [75]

Forensic Dentistry
Many dental age estimation methods, which are a key element in forensic science, are described in the literature. CBCT was established as a non-invasive method to estimate the age of a person based on the pulp–tooth ratio.[76]

Discussion
CBCT scanners represent a significant advancement in dental and maxillofacial imaging. Since their introduction for dental use in the late 1990s [77], there has been an increased interest in these devices. The number of CBCT-related articles published per year has increased tremendously over the last few years. [78]
The clinical applications of CBCT imaging in dentistry are constantly increasing. The most common clinical applications of CBCT are in OMFS, implant dentistry, and endodontics. CBCT has shown limited use in operative dentistry because of the high radiation dose compared to conventional 2D radiography without any additional benefit.
The dental literature on CBCT is promising and indicates that more research is required to explore the benefits of CBCT in forensic dentistry. Although no literature was found on Prosthodontic applications of CBCT, the improved standard of care seen in Prosthodontics treatment can be attributed to applications of CBCT found in other dental specialties and related to Prosthodontics, such as bone grafting, soft tissue grafting, prosthetic-driven implant placement, maxillofacial Prosthodontics and Temporomandibular joint disorders. CBCT images are important in special cases that require the assessment of restorability of multiple teeth.
The newest CBCT systems show higher resolution and lower exposure than previous systems, and the new systems are less expensive and more specific for dental use than their predecessors. One of the most clinically useful aspects of CBCT imaging is the availability of highly sophisticated software that allows the large volumes of acquired data to be broken down, processed and reconstructed[79]. This ability makes data interpretation much more user-friendly, particularly if competent technical and educational training is provided to the dentists and technicians.
CBCT also shows disadvantages such as susceptibility to motion artifacts, low contrast resolution, and limited internal soft-tissue visualization capability. Furthermore, due to the distortion of Hounsfield units, CBCT cannot be used for the estimation of bone density. As far as the radiation dose of CBCT imaging is concerned, it is crucial that a radiation dose As Low As Reasonably Achievable (ALARA) is respected. Although CBCT imaging will certainly improve patient care, dentists must possess the anatomical knowledge and the experience to interpret the scanned data accurately. Dentists must evaluate whether these imaging modalities add to their diagnostic knowledge and raise the standard of dental care or simply place the patient at a higher risk.

Basic principles on the use of CBCT in dental applications:

Conclusion
CBCT is a technology with potential for providing the dental profession with a new imaging alternative to conventional IOPA’s/OPG’s and with the added advantages of improved accuracy and 3-D visualisation of anatomical structures in the orofacial complex.The use of CBCT technology in clinical dental practice provides a number of advantages for maxillofacial imaging.

These include:
1)    Rapid Scan Time
2)    Beam Limitation
3)    Image Accuracy
4)    Reduced patient radiation dose compared to conventional CT
5)    Interactive display modes unique to maxillofacial imaging
However discretion has to exercised on part of the prescribing dentist. To this end, the European Academy of Dento Maxillofacial Radiology has developed the following basic principles on the use of CBCT in dentistry [80]

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