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July 19-25, 201020 Endo Tribune United Kingdom Edition dimensional periapical X-rays. CBCT makes this a breeze. Car- los Estrela, et al (5) concluded that: ‘CBCT seems to be useful in the evaluation of IRR [inflam- matory root resorption] and its diagnostic performance was better than that of periapical radiography.’ Fig 9 shows a PA with suspected external inflammatory root resorption on the mesial of the second molar. Figs 10 and 11 show the location and extent of the defect much more precisely on CBCT. One can even measure how close to the pulp it gets! Difficult anatomy (upper molars especially), dens-in- dente, severe curves, etc Here is another case where the anatomy hid the lesion. The PA was inconclusive (Fig 12). The patient was swollen and all the teeth quite tender. Instead of guessing, I could tell for certain which tooth was the cause of his pain and swelling with CBCT (see Fig 13). Maxillary sinus involvement The patient in Figs 12 and 13 is an MD radiologist who was di- agnosed by a fellow radiologist with a sinusitis. Unfortunately they missed that an infected up- per first molar was the source of the sinus infection. Fig 14 shows the lesion on the palatal root had perforated the sinus floor. Fig 14a is a medical CT that shows the sinus infection but not the dental cause. Gaggers, physically chal- lenged, patients unable to tolerate intraoral X-rays We all have a few of these. Some patients tolerate treatment just fine, but cannot stand to have film, the sensor, or a phosphor plate in their mouth. Pre and post treatment X-rays taken with CBCT is a breeze for them. Trauma cases Are the roots fractured, is the bone fractured? You often can’t tell if the buccal plate is broken and the tooth subluxated in a trauma case. CBCT will usu- ally show the extent of such in- juries. Fig 15 illustrates a badly fractured tooth from trauma. It is easy to see the extent of the fracture. Retreatment etiology (per- foration, missed canals, inad- equate root canal filling etc) I routinely take CBCT on any retreatment case. Knowing that there is a missed canal, a perfo- ration, inadequate filled canals, or some other etiology invisible on 2D images gives me an ad- vantage in recommending re- treatment versus surgery, versus extraction. Surgery planning (apico, reimplant, endo/perio, perforations, mental nerve, inferior alveolar nerve, max- illary sinus) Knowing the size and extent of the peripical lesion as well as its proximity to the nerve or si- nus, takes the guess work out of endodontic surgery. Suspected pathologic lesions size and location Again, it is good to know what you are up against. Calcified canals Location and existence of calci- fied canals are easier visualised on 3D CBCT than on 2D periapi- cal radiographs. Locate extra canals, calcified canals, MB2 MB3) Do you need to chase the MB2 ca- nal until you perforate or does it join the MB1 just a couple of mm beyond where you are search- ing? Preoperative CBCT tells you that for sure. Here is a case (see Figs 18,19,20) with three canals in the mesial root of a lower sec- ond molar. Not common, but you know they are probably there. I found it with a scope and didn’t have a pre treatment CBCT but it looks cool on the report to the referring doctor. Facial pain cases to rule out odontogenic etiology It makes you more confident in making the referral to the oral facial pain specialist or neurolo- gist when you can be sure there isn’t a lesion on the tooth the pa- tient thinks is the cause of their neuralgia and you get a normal response to pulp tests. Endo-perio cases CBCT is very useful in determin- ing the extent and location of periodontal bone loss. Fuhr- mann et al (6) showed that only one out of 14 furcation defects were visible on periapical x- rays where all 14 were vis- ible on CBCT. How much bone is lost, does the endo lesion communicate with the perio defect? Here is a case of an upper bicuspid (Fig 21) with e xtensive periodontal bone loss to the apex. The pulp remained vi- tal to cold tests. Implant planning and place- ment This is a whole presentation in itself. Hans-Joachim Nickenig et al (7) concluded that CBCT guided implant placement is “significantly more accurate than free-hand insertion”. If you are placing implants, it is much easier to treatment plan and place them with a guide generated by CBCT than to just “eye ball” it. Even basic software allows measurement of bone, tracing the nerve and virtual placement of implants (Fig 22). Here is a case (Fig 23) from a well-respected oral surgeon who does a lot of implants and proba- bly wishes he had taken a CBCT to guide him in this case. Measure canal length In most cases, my CBCT is more accurate in determining tooth and canal length than an intra- treatment 2D image or an apex locator. Figure 24 shows case I measured accurately on CBCT without using trial length PA or apex locator. Intra-operative to find canals It is easy to demonstrate with two-dimensional if you are off to the mesial or distal on a calcified canal but what if you don’t know if the canal is to the lingual of buccal of where you are search- ing. Three-dimensional CBCT shows that precisely and saves time and anxiety. Implant placement guidance Using a CBCT generated surgical guide certainly helps avoid misplacing implants and makes the whole process much more predictable. Post-treatment evaluation for healing Several articles describe how useful CBCT is for recall to de- termine if lesions are healing or not. Conclusions Can we practice endodontics without CBCT? Yes, we did it for years, but then some of us used to work without microscopes, digital x-rays, and apex locators. Why not have the best informa- tion available to make your di- agnosis and treatment plan? The more you know about the patient’s anatomy and the shape and number of roots and canals in those roots, the better you will be to diagnose and treat their dental disease. We live and treat patients in a 3D world. Why not use 3D CBCT to better visualise anatomy and pathology? DT page 19DTß References 1) What is Cone Beam CT and how does it work? Scarfe &. Farman, Dent Clin N Am 52 (2008), 707–730 2) Comparison of Periapical Radiography and Limited Cone-Beam Tomography in Posterior Maxillary Teeth Referred for Apical Surgery: Low, Kenneth et al (JOE, Vol 34, Number 5, May 2008 3) Use of cone-beam volumetric tomography in the diagnosis of root fractures, Bernardes et al (OOOOE 2009; 108: 270-277) 4) Detection of Vertical Root Fractures in Endodontically Treated Teeth by a Cone Beam Computed Tomography Scan, Hassan et al (JOE 2009; 35:719–722) 5) Method to Evaluate Inflammatory Root Resorption by Using Cone Beam Computed Tomography. Carlos Estrela, et al. JOE November 2009 (Vol. 35, Issue 11, Pages 1491-1497) 6) Furcation involvement: comparison of dental radiographs and HR-Ct slices in human specimens. Fuhrmann RA, Bucker A, Diedrich PR. J Periodontal Res 1997;32:409 –18 7) Evaluation of the difference in accuracy between implant placement by virtual planning data and surgical guide templates versus the conventional free-hand method – a combined in vivo – in vitro technique using cone-beam CT (Part II) Hans-Joachim Nickenig et al. Journal of Cranio-Maxillofacial Surgery DOI: 10.1016/j.jcms.2009.10.023 About the author Dr Jones has been in private practice limited to endodontics in the greater Kansas City area for 31 years. He re- ceived a certificate and Masters of Sci- ence in Dentistry in endodontics from the University of Nebraska, Lincoln in 1978. He practiced general dentistry in Lawrence, Kansas for over 2 years af- ter graduating in 1973 with distinction with a DDS from University of Missou- ri, Kansas City. Prior to dental school, he attended the University Of Kansas School Of Pharmacy. He was one of the first Endodontists in his area to utilise computers in the office (late 1980s), digital radiography (early 1990s) and Cone Beam CT (2009). He has lectured on Endodontic Diagnosis, Maximising the Use of Technology in Your Personal and Professional Life, Dental Implants from an Endodontist Prospective, and Three Dimensional Cone Beam Com- puted Tomography in Dentistry. He is a member of Omicron Kappa Upsilon and Phi Kappa Phi honorary societies. He is a member of the American Asso- ciation of Endodontists, the American Dental Association, the Kansas Dental Association, the Fifth District Dental Society, the Chicago Dental Society, the Kansas City Dental Implant Study Club, the Dental Abstract Study Club, and the American Academy of Oral and Maxillofacial Radiology. He is an as- sociate professor in Endodontics at the UniversityOfMissori,KansasCitySchool Of Dentistry. Fig 12: PA upper molars Fig 15: fractured lower molar Fig 17: CBCT Missed ML canal. Fig 16: PA Failure etiology uncertain Fig 14: CBCT sinus perforation by lesion (arrow) Fig 18: PA-How many canals in mesial root of lower second molar? Fig 20: CBCT coronal view shows it too! Fig 22: Implant planning Fig 23: oops Fig 19: CBCT axial view shows, three canals in the mesial root of a lower second molar. Fig 21: CBCT Perio not endo Fig 24: exact length measured on CBCT