Radiology in Endodontics:

PRESENTER: KIFAMULUSI ERISA 20/U/16071 BDS IV

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Objectives:
 Introduction.
Radiography Techniques in endodontics.
Interpretation of Radiographic Landmarks.
Digital periapical radiographs.
 CBCT imaging.
Clinical applications for radiology in Endodontics.

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 Introduction:
Radiography is an integral part of Endodontics.
 Radiographs are used for prevention, diagnostics, therapy, and follow-up.
History; Shortly after Dr Otto Walkhoff took the first dental radiograph of his teeth in
1895, Dr Edmund Kells first determined endodontic working length by using dental x-rays
in 1899, and in 1900, Dr Weston Price first suggested the use of radiographs to evaluate
the adequacy of root canal fillings.
Periapical radiographs are the most frequently used type of radiographs for endodontic
treatment. Gives 2D.
Bitewing radiographs are often taken to evaluate restorability before initiating treatment
or to check for coronal leakage and decay.
Occlusal and lateral cephalometric radiographs are used after dental and facial trauma
to identify root or alveolar fractures by providing additional views compared with
periapical or panoramic radiographs.

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Ctd,…..
Cone-beam computed tomography (CBCT); provides a 3-dimensional (3D)
assessment of oral structures. It is now widely used in addition to periapical
radiographs or instead of some traditional imaging techniques, such as occlusal
radiographs.

TECHNIQUES:

paralleling technique.;
Angulated technique.
The SLOB rule (same lingual opposite buccal) technique. Is a standard
technique.

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paralleling technique
 Is primarily recommended for endodontic periapical radiographs.

 It allows for projections with minimal geometric distortions and has a high
level of reproducibility, which is beneficial for comparison with other
radiographs throughout a procedure.
 Briefly, a sensor is placed parallel to the long axis of the tooth undergoing
treatment and exposed using radiographs perpendicular to the sensor surface.
Special sensor holding devices, such as radiograph holders or hemostats, are
required to align the sensor precisely with the radiograph tube.
 In the maxilla, the sensor may have to be placed at the palatal vault’s height in
the midline and in the mandible must displace the tongue toward the midline.
 Compromises may be necessary for patients with limited mouth opening, a
severe gag reflex, or poor tolerance to the sensor.

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 bisecting angle technique:
 Lets radiographs pass perpendicular to the angle bisector of the angle formed by
the tooth’s long axis and the radiograph sensor.
 No holding devices are required
 For conventional PA and bitewing radiography, its unreliable to achieve geometric
accuracy, and distortions of anatomy are common.
 It is difficult to use rectangular collimation with this technique, as extension cone
paralleling techniques are used with rectangular collimation to achieve maximum
geometric sharpness and increased contrast of the resultant image.
 It produces an only minimal distortion of the tooth length on the resultant images.
However, the superimposition of adjacent anatomic landmarks or pathologic features
may lead to difficulties in interpretation. For example, the superimposition of the
maxilla’s zygomatic process over the root apices of molar teeth will often occur,
which results in a characteristic radiopacity that renders interpretation difficult.

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 Adjustments in Vertical and Horizontal Angulation:
Using the SLOB rule, in identifying the relative spatial
or buccal-lingual location of an object within the tooth
or alveolus.
It combines an orthoradial PA radiograph taken at zero
horizontal angulation with additional mesial and/or
distal eccentric radiographs.
E.g, working length film; if the eccentric direction of
the radiograph beam is directed from mesial, a lingual
canal will appear mesially on the image.
 if the radiograph beam is directed from distal, the
lingual canal will appear distally.
SLOB rule can be applied to verify the presence or
absence of foreign bodies or periapical lesion if
radiopaque or radiolucent shadows are superimposed
on an orthoradial radiograph.

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Interpretation of radiographs according
to appearance; (Landmarks)
Appearance Tentative finding
Black/gray area • Decay
• pulp
• Gingiva or space between teeth
• Abscess
• Cyst
White • Enamel
• Restoration (metal, gutta-percha, etc.)
Creamy white area • Dentin appears as creamy white
area
White line around teeth Lamina dura around teeth

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 Digital Dental Radiography
Require an electronic sensor or detector, an analog to digital converter, a computer, and a
monitor or printer for image of the components of imaging system.
CCD System; consist of X-ray or light sensitive phosphorus on a pure silicon chip;
converts incoming X-rays to a wavelength that matches the peak response of silicon.
Radiovisiography (RVG); composed of three major parts:
(1). Radio part; Sensor transmits information via fiber-optic bundle to a miniature CCD
(2). “Visio” part; receives and stores incoming signals during exposure and converts them
point by point, It consists of a video monitor and display processing unit.
(3). Graphy” part; consists of digital storage apparatus; connected to print out or mass
storage devices for immediate or later viewing.
Phosphor Imaging System; Is an indirect digital imaging technique. The image is
captured on a phosphor plate as analogue information and is converted into a digital
format when the plate is processed.

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Periapical radiographs

Sequence of Periapical Radiographs in Root Canal Therapy:

Periapical radiographs are essential for endodontic therapy and they are used for;
 diagnosis
preoperative assessment and and patient communication.
Interpretation of root and root canal system morphology
verification of procedural steps
 postoperative assessment of the root filling (obturation)
long-term evaluation of the treatment outcome (follow-up).

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Applications of PA in Endodontics;
(1). Diagnosis
 Help to know extent of caries, restoration, evidence of pulp capping or pulpotomy.

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Anatomy; Of pulp cavity, curvature
of canal, number of roots and canals,
variation in root canal system, that is,
presence of fused or extra roots and
canals, bifurcation or trifurcation in the
canal system if present.
Help to know pulp conditions present
inside the tooth like pulp stones,
calcification, internal resorption, etc.
Provides information on orientation
and depth of bur relative to pulp cavity.
Help in knowing external resorption,
thickening of periodontal ligament,
extent of periapical, and alveolar bone
destruction.

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 (2).Treatment
Working length determination: In this,
radiograph is used to determine the distance
from the reference point to apex . By using
different cone angulations, superimposed
structures can be moved to give clear image.
Master cone radiographs: used to
evaluate the length and fit of master gutta-
percha cone.
Obturation: Radiographs help to know
the length, density, configuration, and the
quality of obturation

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(3).Recall
Evaluate post-treatment periapical
status.
Presence and nature of lesion
(periapical, periodontal, or non-
endodontic) occurred after the
treatment are best detected on
radiographs
Recall radiographs help to
evaluate success of treatment

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Diagnostic and preoperative radiographs:

PA radiographs for endodontic therapy must include the complete area of
interest with the full length of the root and at least 3 mm of periapical bone.
Ideally, these radiographs should be taken using the paralleling technique,
which provides a consistently high quality without shortening or elongation.
One radiograph may be sufficient for a single-rooted tooth.
 For a multirooted tooth, roots and the root canal system may become
superimposed.
A second radiograph with the radiograph beam shifted mesially or distally
following the SLOB rule should be taken. A bitewing image may be necessary to
assess restorability).

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 Disadvantages of PA Radiographs
 Radiograph represents two-dimensional picture of a three-dimensional object
 For a hard tissue lesion to be evident on a radiograph, there should be at least a mineral loss
of 6.6%
 Pathological changes in pulp are not visible in radiograph
 Initial stages of periradicular disease produce no changes in radiograph
 Radiographs do not help in exact interpretation of the lesion, for example, radiographic
picture of an abscess, inflammation, and granuloma is almost same
 Misinterpretation of radiographs can lead to inaccurate diagnosis
 Radiographs can misinterpret the anatomical structures like incisive and mental foramen with
periapical lesions
 Chronic inflammatory lesion cannot be differentiated from healed fibrous scar tissue
 Buccolingual dimensions cannot be assessed from IOPA radiograph.
Therefore, To know the exact status of multirooted teeth, multiple radiographs are needed at
different angles which further increase the radiation exposure.
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 Applications of CBCT in Endodontics
(1).Preoperative Evaluation:
Tooth morphology: detects accurate degree of curvatures of roots
of teeth, aberrations present in teeth, anomalies such as dens
invaginatus or tooth fusion. It can detect MB2 better than 2D
conventional radiography.
Dental periapical pathosis and apical periodontitis: CBCT gives
more accurate images for identification of apical periodontitis;
demonstrate bone defects of the cancellous bone and cortical bone
separately. It can also tell invasion of lesion into the maxillary sinus,
thickening of sinus membrane, and missed canals.
Diagnosis of different types of root resorption: detection of small
lesions, localizing and differentiation of the external root resorption
from external cervical resorption, internal resorption, and other
conditions.
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Cone-Beam Computed Tomography
Clinically practical technology demonstrating application of 3D
imaging for endodontic considerations.
CBCT has cone shaped X-ray beam that captures a cylindrical or
spherical volume of data, described as the field of view.
Accurate and immediate 3D radiographic images
CBCT systems utilize a pulsatile X-ray beam, therefore, actual
patient exposure time can be very low as 2–10 s.

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Ctd,…

Root fracture: CBCT provides accurate assessment of

dentoalveolar trauma, especially root fractures as compared to
conventional radiography
In surgical endodontics: It tells accurate spatial relationship of the
target tooth to adjacent anatomical structures like inferior alveolar
nerve, mental foramen, and maxillary sinuses.
Assessment of traumatic dental injuries: It helps in accurate
detection of horizontal root fractures, degree and direction of
displacement related to luxation injuries than multiple periapical
radiographs

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(2).Postoperative Assessment

 It helps in monitoring the healing of apical lesions accurately as

compared to conventional radiography
CBCT is used to initial and subsequent monitoring of the integrity
of root canal obturation
CBCT helps in determining the precise nature of a perforation and
healing on subsequent treatment.

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 Refferences
(1). Text book of Endodontics, Nisha Garg, Amit Garg, 4th Edition
(2). Grossman’s Endodontic Practice, 14th Edition.
(3). Pocket dentistry.

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