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Cone Beam in Endodontics - Bertrand Khayat and Jean-Charles Michonneau
Cone Beam in Endodontics - Bertrand Khayat and Jean-Charles Michonneau
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Continuing Education
2 CE credits
This course was written for endodontists and general dentists
Resolution
Endodontics requires an image as precise as possible. Root canal anatomy, calcifications and the presence of hairline fractures should ideally be viewed on a three-dimensional image. The image acquired by the cone beam is composed of voxels that determine the image resolution. The voxels are isotropic, i.e. they have edges of identical dimensions. Thus, slices rebuilt from these voxels will have the same spatial resolution whatever their orientation. The size of the voxels varies depending on the type of device (Table 1). The size of the voxels is on average 0.15mm which is slightly lower than the size of a pixel on a conventional scanner. However, the final usuable resolution will be obtained only after computerising the image. There are great inconsistencies in the quality of this process which is crucial for the final image. Some models with a small size voxels offer blurred/hazed three-dimensional images and therefore are more difficult to use in endodontics. Haze is a defect that degrades the image quality. It is generally caused by a lack of homogeneous response of the digital sensor. The surface receptors of some sensors are more sensitive than others to ionizing radiation and create a stronger signal from the same exposure. Haze causes loss of sharpness in the detail and creates grain on the picture. This haze is structural and permanent; it remains the same for each exposure. It may be reduced using computer processing. Each device has its own three-dimensional reconstruction algorithms; there are wide inconsistencies in the grain and sharpness of the image, regardless of the voxel size.
Specific problems
Crowns or any other metal element in the mouth cause many artifacts during the acquisition of the threedimensional image due to the absorption of the X-ray beam. The nature of the metal leads to great variations in the quality of the image. The alteration of the image is slightly lower with the cone beam than with the conventional scanner. In endodontics, it is common to examine teeth with posts and prosthetic restorations and artifacts produced by metal limit the image reading. Sometimes interpretation even becomes impossible (Figure 1a). The computer process used by the cone beam should mitigate against this problem (Zhang et al, 2007). Manufacturers are actively working on this aspect of image processing which is at present the main shortcoming of three-dimensional imagery. Currently, Planmeca is the first to adopt image processing software for their cone beam Promax, which minimizes the effect of metallic artifacts (Figures 1b and 1c).
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1a Figure 1a: Cross section showing many metal artifacts due to prosthetic restoration
1b Figure 1b: Section made with cone beam Promax (Planmeca) without any specific image processing (arrow)
1c Figure 1c: The same section after computer processing using Planmeca software. Metal artifacts are virtually missing and a greatly improved image is clearly seen (arrow)
2a Figure 2a: Standard radiograph of 24 showing no problems. The lamina dura seems intact and periapical bone trabeculae normal
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2c
Figures 2b and 2c: The two sections obtained through three-dimensional imagery clearly show significant apical lesions on the buccal root of 24, having already reached and perforated the buccal cortical bone
Cone beam technology: Conical beam radiation Volumetric image of the X-rayed object Exploration of this volume in three dimensions Definition of the image in voxels Processing of metal artifacts Radiation doses: Significantly lower than the conventional scanner Size range of the digital sensor Area of investigation may be limited to three to four teeth
Promax
I-Cat
Newtom
Accuitomo Iluma
Size of Voxels in mm
0.15
0.125-0.4 0.15-0.3
0.125
0.093
Standard dental X-ray Relevance Cone beam in endodontics: Assessment of the size and location of periapical lesions Assessment of anatomical structures Visualisation of the root canal system Visualisation of perforations and radicular resorption Diagnosis of fractures Cone Beam Standard panoramic X-ray Medical scanner
Radiation dosage
The dose of radiation actually received by the patient during a conventional scan or cone beam is difficult to measure. Modern scientific data provides confusing and contradictory results, making comparison between models difficult. However, it is necessary to give some reliable information to patients and staff
users. The final aim is to estimate the dose received by each patient, the efficient dose (Gibbs, 2000). The latter measures the impact on biological tissues following radiation. It is the dose absorbed by the patient, multiplied by a tissue factor related to the irradiated body. The effective dose is measured in Sieverts.
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Figure 3a: Standard radiograph highlighting a significant periapical lesion on 11 and 12. The lateral incisor is necrotic (cold and electric pulp test). The possible involvement of the central incisor can not be seen on this image Figure 3b: Cross section showing the extent of the lesion at the the apex of 12. The presence of cortical buccal bone in contact with 11 is clearly seen indicating that this tooth is not involved. Only endodontic treatment of tooth 12 is required
3a
3b
Figure 4a: Standard radiograph Figure 4b: Magnified image of the large apical area tooth 22 showing a large lesion the size of which is difficult to assess Figures 4c, 4d, 4e and 4f: Cross sections at different levels showing extensive destruction of the palatal and buccal cortical bone extending to the floor of the nasal cavity
4a 4c 4d
4b 4e 4f
Effective dose = dose absorbed by the x patient tissue factor At the moment it is difficult to establish an accurate comparison between X-ray examinations (Table 2). Only orders of magnitude can be expressed (Gijbels et al, 2005; Ludlow et al, 2006; Mah et al, 2003; Ngan et al, 2003; Tsiklakis et al, 2005). Indeed, the dose received by the patient can only be based on the size of the examined area. A cone beam examination on a section of three teeth will give less radiation than two complete arches. The use of a
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high voltage generator coupled with latest generation digital sensors helps limit the effective cone beam dose.
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Figure 5a: Standard radiograph of 26 clearly showing a periapical lesion on the mesiobuccal root which appears in contact with the sinus floor Figure 5b: The front section shows a boney wall isolating the sinus from the lesion Figure 6a: Standard radiograph of 45 with apical lesion in close proximity to the mental foramen Figure 6b: Frontal section. The periapical lesion is in direct contact with the mental foramen making endodontic surgery impossible Figure 7a: Standard radiograph of a lateral incisor with atypical anatomy difficult to assess Figure 7b: Cross section of this lateral incisor showing two distinct roots. The contour of each root is clearly identified and treatment can be safely undertaken Figure 8a: X-ray of 16 with periapical lesion on the mesial root. Endodontic treatment seems quite satisfactory Figure 8b: Identification on cross section of a second untreated mesiobuccal root canal (arrow)
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5b
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6b
7a
7b
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9b
9a
Figure 9a: The incisors had conventional endodontics on two separate occasions followed by apical surgery but without any improvement clinically or radiographically Figure 9b: Cross section reveals a dual root canal system on 22, explaining the persistence of the periapical lesion (arrow) Figure 9c: Sagittal cross section of 22. Only the buccal canal has been identified and addressed despite multiple interventions. The palatal canal (arrow) has its own apical foramen which has been completely missed during endodontic surgery
9c
10b
Figure 10a: Standard radiograph of 21. A horizontal fracture line seems visible in the cervical third Figure 10b: Cone beam image in transverse view showing a vertical fracture whose prognosis is very unfavorable 10a
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without any image degradation. A new generation of cone beam working only with a reduced sensor size has appeared on the market (Illuma). These new devices offer the same benefits and image definition near to the conventional cone beam at a much lower cost. They limit the investigation zone to a restricted area (three or four teeth) which is sufficient for endodontics. causes of endodontic diseases through three-dimensional exploration of the root canal system. It is possible to check the quality of obturation and the possible presence of an untreated canal. Anatomical complexities (C-shape lower molars, multiple canals in lower premolars, dual canal systems on upper incisors) are mapped to the source of an apical lesion (Figures 8a, 8b and Figures 9a, 9b and 9c). Perforations and stripping of the root during the preparation for a post are also identifiable using the cone beam. The presence of the metal may actually make the interpretation of the image more difficult, even impossible. External and internal resorption can make endodontic treatment very challenging. It is impossible to measure the outline and extent of resorption on standard images (Gartner et al, 1976). Three-dimensional imaging provides a more detailed picture of the resorptive defect and helps to refine the diagnosis. Resorptions are in most cases diagnosed too late, affecting the prognosis of the tooth.
Diagnosis of fractures
Tooth fractures, except in cases of trauma, are generally due to mechanical overload. It used to be thought that they occurred on heavily restored teeth or teeth with large posts. This is not corroborated in the scientific literature. Even teeth with minimal restorations can fracture if the occlusal stress is excessive. Without precise clinical and radiological examination, the diagnosis of vertical root fracture is difficult (Kositbowornchai et al, 2001). Indeed, the fracture line is often located in the major axis of the tooth and passes unnoticed on a standard image. With the cone beam radicular fractures can be clearly seen regardless of their location (Figures 10a and 10b). Unfortunately, fine vertical cracks, which are much thinner than fractures, are not visible on cone beam images. Microscopic examination of the root surface, thorough periodontal probing and percussion tests are necessary to establish an accurate diagnosis.
Conclusion
The cone beam seems to have eliminated many of the initial flaws of the medical scanner. The apparatus is more compact, more convenient to use and meets the standards of use in a dental practice. The acquisition of a threedimensional image is rapid with little additional radiation to the patient. The volume obtained through adapted software allows us to explore each area in all dimensions. In endodontics, the cone beam has become a valuable tool to refine diagnosis and anticipate potential complications in treatment. The resolution of the latest equipment and especially processing after acquisition improve the quality of the image. It is now possible to view the root canal system of each tooth and effectively eliminate most metal artifacts. It would be desirable in the near future to analyze finer structures such as cracks, by improving the definition of the cone beam image.
References
For a full list of references please contact the editor at siobhan.lewney@fmc.co.uk. Z
Acknowledgment
This article has been reprinted with kind permission from Realites Cliniques.