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I 23 special _ advancements in endodontics I roots4_2010 _Precise 3-D visualisation The ability to visualise the complexities of pulpal anatomy has had a tremendous impact on our ability todiagnoseandtreatcomplexendodonticdisease.3–6 For decades, the microscope has enhanced the qual- ity of our endodontic treatment. The knowledge that greater expertise and quality outcomes can result from increased visualisation is self-evident. Cur- rently, cone beam computed tomography (CBCT) allows us to visualise the intricacies of individual pulpal anatomy more clearly in 3-D.7 CBCT uncovers detailsofanatomyinthepulpalsystemandboneprior to initiating treatment, which in turn guides diagno- sis and contributes significantly to more predictable treatment.8–9 The following cases illustrate examples ofhowCBCTcanaidtheclinicianinendodonticdiag- nosis and treatment. When a patient presents with swelling of the lower right vestibule, a comprehensive examination is performed, including a 2-D digital peri-apical radiograph.Inthiscase,amid-root,cystic-appearing, radiolucent lesion was noted without peri-apical involvement(Fig.1a).UponCBCTevaluation,alateral portal of exit was visualised in the centre of this osseous defect, which aided in the diagnosis of a le- sion of endodontic origin (Fig. 1b).10–11 Once compre- hensive pulpal testing had been completed, tooth #28 was confirmed to be non-vital. After analysing the information provided by the CBCT image, the infected lateral system was more easily located and instrumented with the sharp J-curve of a stiff #15 hand file (Fig. 1c). Treatment was enhanced by directly instrumenting this aspect of the pulpal system, as we know that this increases disinfection.12 After non-surgical treatment had been completed, surgical intervention was perfor- med owing to the appearance and size of the lesion. When the radicular cyst (confirmed histologically) hadbeenremoved,thesurgicalmicroscopedisplayed the lateral portal of exit to be sealed with gutta- percha (Fig. 2a). In addition, the sealed upward- facing lateral system can be seen on the post-opera- tive digital image (Fig. 2b). Comprehensive treatment of the entire pulpal system dictates endodontic success.13 Figures 3a and b illustrate the common challenge that arises as the result of a second mesio-buccal system (MB2) in upper molars. Once clinicians visualise whether complex pulpal anatomy is present with CBCT, they canconfidentlyandconservativelylocateitunderthe microscope. With utilisation of this new technology, incomplete endodontic therapy should be a thing of the past. CBCT has a profound impact on our ability to locate and treat calcified pulpal systems.14 Figure 4a illustrates a calcified molar in need of endodontic therapy. Upon initial microscopic treatment, diffi- culty in locating the mesio-lingual (ML) system was encountered. Calcium hydroxide was placed and a CBCT image was taken. The location of the elusive canal was visualised as being patent and at the level of the current conservative exploration, but 0.25mm tothelingual(Fig.4b).Uponmicroscopicre-entryinto thecase,theMLcanalwasconservativelylocatedand comprehensive treatment was completed (Fig. 4c). _Relentlesspursuitofcompletedisinfection Revolutionaryadvancementsinendodonticdisin- fectionhaveintensifiedourdesiretoreachhigherlev- elsofdisinfection.Onesuchdevicethatfacilitatesthis goal is the EndoVac (Discus Dental; Figs. 5a & b).15–17 The EndoVac provides thorough irrigation of the complete root-canal system, including the critically Figs. 3a & b_CBCT technology is commonly used for confirmation of the presence and location of an MB2. This allows for confident, conserva- tive and comprehensive treatment. Fig. 3a Fig. 3b Fig. 4a Fig. 4b Fig. 4c Fig. 4a_A calcified molar in need of endodontic therapy. Fig. 4b_After initial exploration for the calcified ML system, calcium hydroxide was placed and a CBCT image was taken. The location of the elusive canal was visualised to be patent and at the level of the current conservative exploration, but 0.25mm to the lingual. Fig. 4c_CBCT information allowed for the conservative location of the calcified ML system and completion of comprehensive treatment of the entire root-canal system.