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Radiology in Endodontics
- 1. RADIOLOGY IN ENDODONTICs Presented By Jean Michael 1
- 2. History • 1895 – Discovery of cathode rays by Roentgen • 1895 – Dr. Otto Walkoff took the 1st dental X ray (of his own teeth) • 1899 – Dr. Edmund Kells used Radiographs to determine the root length during RCT • 1900 – Dr. Weston Price advocated the use of radiographs to check the adequacy of root canal fillings 2
- 3. How To Obtain A Good Radiograph 1. Proper placement of film in the patient’s mouth 2. Correct Angulation of the cone in relation to the film and oral structures 3. Correct exposure time 4. Proper developing technique 3
- 4. Relevant Findings For An Endodontist • Presence of Caries that may involve or threaten to involve the Pulp • Number, course, shape and length of root canals • Calcification or obliteration of pulp cavity • Internal and External Resorption • Thickening of Periodontal Ligament • Nature and extend of Periapical and Alveolar Bone Destruction 4
- 5. • Diagnose abnormalities like Dilaceration and Taurodontism • Diagnose fracture of root • To estimate and confirm the length of root canals before instrumentation (working length determination) • To confirm the position and adaptation of master cone • Evaluation of outcome of root canal therapy (post operative radiograph) 5
- 6. Types of Radiographs • Intraoral Radiographs – Intraoral Periapical (IOPA) – Occlusal Radiographs – Bitewing Radiographs • Extraoral Radiographs – Panoramic Radiographs – Lateral Cephalograms 6
- 8. Occlusal Radiographs 8
- 9. Bitewing Radiographs 9
- 10. Panoramic Radiograph 10
- 11. Lateral Cephalogram 11
- 12. Disadvantages of Radiographs • Radiographs are 2D shadow of a 3D Object • They are only suggestive and not the final evidence in judging a clinical problem • Bucco-lingual dimension cannot be assessed in an IOPA • The bacterial status of the hard and soft tissues cannot be determined • Chronic inflammatory tissues cannot be differentiated from healed fibrous scar tissue 12
- 13. • Lesions of the medullary bone are undetected in the radiographs till there is substantial bone loss and the involvement of cortical bone • For a hard tissue lesion to be evident on a radiograph, there should be at least a mineral loss of 6.6 % • Even a single error in the procedure can render a radiograph useless • Over exposure to X rays are harmful to the body and strict precautions are to be maintained for the patient and the operator 13
- 14. Techniques Employed for IOPA • Paralleling Technique • Bisecting Angle Technique 14
- 15. ParallelingTechnique • Film is placed parallel to the long axis of the tooth to be radiographed • The film is exposed using X rays which are perpendicular to its surface • Requires special film holding devices 15
- 16. Film Holding Devices 16
- 17. Bisecting Angle Technique • The X rays pass perpendicular to the angular bisector of the angle formed by the long axis of the tooth and the X ray film • No film holding devices are required 17
- 18. Normal Anatomical Landmarks 18
- 19. Enamel, Dentin & Pulp 19
- 20. Cervical Burnout 20
- 21. Radical Pulp & Apical Foramen 21
- 22. Radical Pulp 22
- 23. Lamina Dura 23
- 24. Lamina Dura (extracted tooth) 24
- 25. Double Periodontal Ligament and Lamina Dura 25
- 26. Periodontal Ligament Space 26
- 27. Periodontal Ligament Space 27
- 28. Intermaxillary Suture 28
- 29. Incisive Foramen 29
- 30. Soft Tissue Shadow of the Nose 30
- 31. Nasolacrimal Duct 31
- 32. Inferior Border of Maxillary Sinus 32
- 33. Neurovascular Canals in the Walls of Maxillary Sinus 33
- 34. Zygomtic Process of Maxilla 34
- 35. Shadow of Nasolabial Fold 35
- 36. Genial Tubercles 36
- 37. Lingual Foramen 37
- 38. Mental Foramen 38
- 39. Mental Foramen 39
- 40. Mandibular Canal 40
- 41. Mandibular Canal 41
- 42. Nutrient Canals 42
- 43. Nutrient Canals 43
- 44. Mylohyoid Ridge 44
- 45. Mylohyoid Ridge 45
- 46. Coronoid Process of Mandible 46
- 47. IOPA Radiographs in Endodontic Therapy • Diagnostic Radiographs • Working Radiographs • Post operative Radiographs • Follow up Radiographs 47
- 48. Diagnostic Radiographs • Ideally, these radiographs should be taken using paralleling angle technique • They should be of high quality without any foreshortening or elongination • They help for proper diagnosis of the case • These radiographs helps in determining the prognosis by comparison with post operative and follow up radiographs 48
- 49. 49
- 50. Comparison between Diagnostic and Follow up Radiographs Periapical Cyst Before RCT Complete Bony repair after RCT 50
- 51. Working Radiographs • These radiographs are used for determining the position of instruments – files etc during the procedure • These radiographs are to be taken without removing the rubber dam as it can cause contamination of the operating field • Bisecting angle technique can be used • A better alternative is the use of a hemostat as a film holding device 51
- 52. Radiograph showing Endodontic Instruments & Rubber Dam Clamp 52
- 53. Working Radiograph with Master Cone 53
- 54. Working Radiographs of same tooth using Different Angulations 54
- 55. Advantages of using a Hemostat • Film placement is easier when the opening is restricted by the Rubber dam and frame • In the mandibular posterior area, the closing of mouth relaxes the mylohyoid muscle permitting the film to be placed farther apically 55
- 56. • The handle of the hemostat is a guide to align the cone in a proper vertical and horizontal angulation • There is less risk of distortion caused by finger pressure and film displacement as in bisecting angle technique • Any movement can be detected by the shift of the handle and corrected before the exposure 56
- 57. Using a Hemostat as a Film Holder 57
- 58. Film is Perpendicular to X Ray Beam 58
- 59. View From Above 59
- 60. Mesial Angulation of X ray Beam 60
- 61. Distal Angulation of X ray Beam 61
- 62. Rubber Dam – Is It Necessary ? 62
- 63. Postoperative Radiographs • They are used to evaluate the endodontic treatment • They are taken after removing the rubber dam • Ideally paralleling angle technique should be used • They can be compared with the diagnostic radiograph 63
- 64. Post Operative Radiograph 64
- 65. 65
- 66. Overdenture Abutment 66
- 67. Overextension into Inferior Alveolar Canal leading to Permanent Paresthesia 67
- 68. Follow-up Radiographs • These radiographs are taken to evaluate the prognosis of the endodontically treated tooth • After obturation, the tooth may have to undergo procedures like core build up, crown fabrication etc • The follow up radiograph gives the health of the periodontium and the tooth by evaluating the presence of root resorption, other treatment failures etc 68
- 69. 69
- 70. External Root Resorption Before Bleaching 2 Years After Bleaching 70
- 71. Follow up Radiographs After RCT 71
- 72. Recovery from Furcal Bone Loss after RCT 72
- 73. Endo – Perio Lesion 73
- 74. Vertical Angulation • Elongation – Corrected by increasing the vertical angle of the central ray • Foreshortening – Corrected by decreasing the vertical angle of the central ray 74
- 75. Horizontal Angulation Clarke’s Rule (S.L.O.B Rule) • The object that moves in the SAME direction as the cone is located toward the LINGUAL • The object that moves in the OPPOSITE direction as the cone is located toward the BUCCAL 75
- 76. 76
- 77. Central Ray Perpendicular to the Film 77
- 78. Central Ray directed 20˚ Mesial to film 78
- 79. Working Radiographs with Instruments inside the Root Canals Superimposition of Files 4 separate Files in root canals 79
- 80. X-ray Beam passing through Two Thicknesses of Root Structure 80
- 81. X-ray Beam aimed 20˚ Mesially through Single Thicknesses of Hourglass Root 81
- 82. Radiographic Diagnosis Of Pathologic Conditions 82
- 83. Caries Involving the Pulp 83
- 84. Pulp Calcification following Avulsion 84
- 85. Internal Resorption following Trauma 85
- 86. Internal Resorption 86
- 87. Internal Resorption following Trauma 87
- 89. External Resorption following Trauma 89
- 90. Fracture of Crown Exposing the Pulp Crown Fracture After 3 Years 90
- 91. Fracture of Crown involving Pulp 91
- 92. Root Fracture at Multiple Sites 92
- 93. Fracture Healed by Interproximal Bone 93
- 94. Extensive Wear of Mandibular Incisors 94
- 95. Luxation 95
- 96. Apical Condensing Osteitis 96
- 97. Apical Condensing Osteitis associated with Chronic Pulpitis Just after RCT 1 Year after Treatment 97
- 98. Enostosis (Sclerotic Bone) 98
- 99. Tooth Intruded due to Trauma 99
- 100. Circumferential Dentigerous Cyst 100
- 101. Periradicular Cemental Dysplasia 101
- 102. Radicular Lingual Groove 102
- 103. Dens Invaginatus with Radicular Lesion 103
- 104. Hereditary Hypophosphatemia 104
- 105. Digital Radiography 105
- 106. • The digital systems relies on an electronic detection of an X ray generated image that is electronically processed and reproduced on a computer screen 106
- 107. Advantages • Reduced exposure to radiation • Increased speed of obtaining the image • Possibility for digital enhancement • Storage as digital data in computers • Ease of transmissibility • Elimination of manual processing steps 107
- 108. Intraoral X ray Sensors 108
- 109. Digital Image Enhancement 109
- 110. Inversion 110
- 111. Contrast 111
- 112. Measurement of Angle of Root Curvature 112
- 113. Flash Light 113
- 114. Magnification 114
- 115. Pseudocolour 115
- 116. Linear Measurement 116
- 117. Conclusion • Radiograph is a very powerful tool for a dentist, especially an Endodontist with which he are able to examine the status of hard tissue which are beyond the field of his naked eyes • Application of radiology gives new standards for the diagnosis, treatment and prognosis of a dental problem 117
- 118. REFERENCE • Grossman’s Endodontic Practice 12th edition • Endodontics 6th edition – Ingle • Oral Radiology 6th edition – White & Pharoah 118
- 119. 119
- 120. 120
- 121. 121
Editor's Notes
- Fitting the master gutta-percha cone. A, Cone fit to radiographic terminus. B, Cone is cut back 0.5 mm.When placed to depth, the incisal reference remains the same. C, Compaction film reveals two apical foramina as well as large lateral canal opposite lateral lesion.
- A, Bony lesion in furcation draining through buccalgingival sulcus. The molar pulp is necrotic. B, Obturation reveals the lateral accessory canal. C, Three-year recall radiograph. Total healing is apparent. No surgery was used.
- A vital coronal pulp and associated periradicularresorptive lesions (arrows), most likely to occur in young persons, as demonstrated by a newly erupted, but cariously involved, second molar in a 15-year-old patient. Usually, a periradicular lesion is associated with necrotic pulp, as is the case on the first molar.
- An avulsed left central incisor in a 6-year-old boy was replanted immediately. A,When re-evaluated after 8 weeks, there was still response to electric pulp testing. B, One year after trauma, the tooth was in the normal position and had no discoloration but did not respond to electric pulp testing. The root has continued to develop and the pulp appears to be calcifying. Also note hourglass erosion/resorption cervically(arrows). (Courtesy of Dr. Robert Bravin.)
- Advanced internal resorption of a first molar. The process spread distally from the pulp to undermine restoration and perforate externally. The pulp is now necrotic, as evidenced by inflammatory lesion at apex. The cause of internal resorption may be from deep caries, pulp cap, or trauma from extraction of the second molar.
- Differing pulp responses to trauma. Both incisors suffered impact as well as caries and restorative trauma. It is not clear why one pulp may react with extensive internal resorption and why another pulp may form calcifications. Treatment was successful in the central incisor but unsuccessful in the lateral incisor; the “cork-in-a-sewer” retrofilling failed.
- Extensive internal resorption apparently triggered by iatral causes. Normal condition of teeth prior to crown preparation is seen in “before” radiographs (A and B). Development of internal resorption from high-speed preparation without water coolant is seen 1 year later (C and D).
- External inflammatory resorption. A, Accidentally luxated tooth, radiograph taken 8 weeks after the incident. Note resorption of both dental hard tissues as well as adjacent alveolar bone. B, Immediately after root canal therapy. C, Control radiograph taken 12 months later. Note repair of the alveolus and establishment of a new periodontal ligament space. The root canal procedure arrested the resorptive process. (Courtsey of Dr. Romulo de Leon.)Figure 15-33 A, Internal resorption with a history of trauma. B, Immediately following root canal therapy.
- Fractured premolar restored by endodontics and post-and-core crown. A, Tooth immediately following fracture. B, Restoration and periradicular healing at 3-year recall. Note the spectacular fill of arborization (arrows) at the apex. (Courtesy of Dr. Clifford J. Ruddle.)
- Root fractures involve cementum, dentin, and pulp and may occur in any part of the root: apical, middle, or coronal thirds. B, Fractures may also be Comminuted (arrows).
- A,Healing by interproximal bone. B, Root fracture (arrow) resulting in total separation of fragments. C,Midroot facture stabilizedfor 3 months. D, Note that after removing the splint, the incisal edges are even, yet a space is apparent between the segments. E, Eightmonths later, bone is now apparent between segments. F, The interproximal space has enlarged further 2 years after the accident. The toothis firm and functional. Note calcification of the pulp space.
- C, Pulps of three incisors have been devitalized by the force of traumatic habit. Acute abscess has separated central incisors. D, One year following root canal therapy, some repair has occurred; however, persistent habit prevents complete healing.
- Tooth luxation with loosening and displacement is often accompanied by fracture or comminution of the alveolar socket. B, Luxation displacement of left central and lateral incisor and canine (arrows). C, After repositioning. D, The incisor required root canal therapy about 3 months later. Canine retained its pulp vitality.
- Apical condensing osteitis that developed in response to chronic pulpitis. Additional bony trabeculae have been formed and marrow spaces have been reduced to a minimum. The periodontal ligament space is visible, despite increased radiopacity of nearby bone.
- Figure 5-9 A, Apical condensing osteitis associated with chronic pulpitis. Endodontic treatment has just been completed. Obvious condensation of alveolar bone (black arrow) is noticeable around the mesial root of the first molar. Radiolucent area is evident at the apex of the distal root of the same tooth. The retained primary molar root tip (open arrow) lies within the alveolar septum mesialto the molar. B, Resolution (arrow) of apical condensing osteitisshown in A, 1 year after endodontic treatment. From a radiographic standpoint, complete repair of both periradicular lesions has been obtained. Reversal of apical condensing osteitis and disappearance of radiopaque area are possible.
- Enostosis. Also known as sclerotic bone. The radiopaque mass (arrows) probably represents an outgrowth of cortical bone on the endosteal surface. It is associated with neither pulpal nor periradicularpathosis and can be differentiated radiographically from condensing osteitis (see Figure 5-9) by its well-defined borders and homogeneous opacity
- Canine
- Circumferential dentigerous cyst developed around the crown of an unerupted canine. The cyst may be enucleated (care must be taken to avoid the incisor) and the canine brought into position with an orthodontic appliance.
- Initial – Later – Intermediate - Mature
- Unusual pulp dystrophy seen with hereditary hypophosphatemia. Incomplete calcification of dentin and huge pulps leave these teeth vulnerable to pulp infection and necrosis.