Endodontic Radiography

Prof.Dr Mehmet Omer Gorduysus DDS,PhD

Radiography is used in endodontics for:

Diagnosis
Treatment: Working films
Technical assessment of treatment
Review healing and tissue
responses -
After endodontic treatment
After surgery
After trauma
Radiography
Techniques

Parallel technique

Bisecting angle technique

Parallel Technique
Bisecting Angle Technique
Parallel -v- Bisecting Angle
+ 10%
 Parallel Technique

Parallel technique is more accurate than the

bisecting angle technique

BUT still have approx. 10% magnification

Since the x-rays come from a point source
Can minimise with rectangular collimation
and long cones
 Effect of Magnification

A tooth that is 21.0 mm long would

appear to
be about 23.0 mm on the radiograph
Since 10% of 21.0 mm is 2.1 mm
Effect of Magnification
Radiography
Techniques

Parallel technique

Modified parallel

technique
Bisecting angle

technique
 Modified Parallel Technique

To overcome the 10% magnification that

occurs with the parallel technique

Method:
Increase the vertical angle of the central
beam by ~ 15
 Modified Parallel Technique

To overcome the 10% magnification that

occurs with the parallel technique

Method:
Increase the vertical angle of the central
beam by ~ 15
Rationale
Foreshortens the image slightly
 Positioning Devices

Most accurate to least accurate:

Rinn XCP
Styrofoam bite block + Parallel
Technique
Haemostat with bite block
Patients finger
Patients finger technique had the greatest amount
of film bending
Rinn XCP Kit
All Radiographic Techniques
Principles to Follow

Must be simple to use

Use a positioning device with beam alignment
Must give an accurate image
No film distortion, bending, etc
Stable position with no hands needed
Reproducible image over time
All Radiographic Techniques
Rinn XCP Kit

Must be simple to use

Use a positioning device with beam alignment
Must give an accurate image (+ modified parallel tech)
No film distortion, bending, etc
Stable position with no hands needed
Reproducible image over time
 Rinn XCP Kit

Must be simple to use

 Rinn XCP Kit

Use a positioning device with beam alignment

 Rinn XCP Kit

Must give an accurate image

Radiographic technique and prediction of tooth length

Bhakdinaronk & Manson-
Manson-Hing 1981

Most accurate to least accurate:

Rinn XCP

Styrofoam bite block + Parallel

Technique
Haemostat with bite block

Patient
Patients finger
Patients finger technique had the greatest amount
of film bending
 Rinn XCP Kit

Must give an accurate image

RINN with the Parallel Technique

Average deviation was only:

Tooth length: 0.5 mm
Crown width: 0.2 mm
 Rinn XCP Kit

No film distortion, bending, etc

 Rinn XCP Kit

Stable position with no hands needed

 Reproducible image over time

Pre-op RCF 1 yr later 4 yr Recall

Pre-op RCF 1 yr later

2 yr Recall 4 yr Recall
 All Radiographic Techniques
Rinn XCP Kit

Must be simple to use

Use a positioning device with beam alignment
Must give an accurate image (+ modified parallel tech)
No film distortion, bending, etc
Stable position with no hands needed
Reproducible image over time
 Rinn XCP Kit

Use for ALL diagnostic radiographs (NOT just Endo!)

Use for all post-RCF and follow-up radiographs
Use for trauma reviews
Use whenever Rubber Dam is not in place
Using the Rinn Holder

Anterior Teeth
Using the Rinn Holder

Upper Anterior Teeth

Using the Rinn Holder

Lower Anterior Teeth

 Using the Rinn Holder

Posterior Teeth

UL / LR UR / LL
Using the Rinn Holder

Upper Posterior Teeth

Using the Rinn Holder

Upper Posterior Teeth

Using the Rinn Holder

Lower Posterior Teeth

?
Using the Rinn Holder
Styrofoam bite block
 Radiographic Interpretation
The Importance of Accurate
Radiographs
Endodontics
Root Canal Length Estimation
 The Importance of
Accurate Radiographs

Correct Diagnosis
 Size 0 - 22 x 35 mm - 770 mm
Size 1 - 24 x 40 mm - 960 mm
Size 2 - 31 x 41 mm - 1271 mm
 Recommended Film Sizes

Size 2 - standard film used for PAs

Size 1 - narrow arches, anterior teeth

Size 4 - occlusal views

Viewing Conditions
 Viewing Conditions

Correctly mounted
Block out peripheral light
Even light source
Magnify the image
Troll Viewer
 Radiographic Interpretation

Accuracy of interpretation affected by many

factors
Film type & exposure time

Technique & angulations used

Standard of developing

Endodontic file size used

 Radiographic Interpretation

Accuracy of interpretation affected by many

factors
Superimposition of other structures
Bone processes, roots, canals, etc

Foramen position with respect to root

apex
Mesial / Distal or Buccal / Lingual
 Radiographic Interpretation

Accuracy of interpretation affected by many

factors
Density of bone
Trabeculae, cortical plate

Amount of bone that has been resorbed

? How much is required
 Radiographic Interpretation

How much bone loss is required before a radiolucency

can be reliably detected on a PA radiograph ??
Cortical plate involved
Bender & Seltzer 1961(a)

Junctional trabeculae involved

Bender & Seltzer 1961(b)

Cancellous bone involved

Shoha et al 1974, Pitt Ford 1984

Lamina dura destroyed

Lee & Messer 1986, Barbat & Messer 1998
 Radiographic Interpretation

Poor correlation between radiographic interpretation and

the histological findings
Bender & Seltzer 1964, Pitt Ford 1984

Lesion always larger histologically than on radiograph

Bender & Seltzer 1964

Lesion always larger surgically than on radiograph

Farman et al 1998, Scarfe et al 1999
 Radiographic Interpretation

Whenever a periapical radiolucency was observed,

an inflammatory resorptive lesion was always
identified histologically

AND

When no radiographic evidence of periapical

pathosis, inflammation was either mild or absent

Green et al 1997
 Radiographic Interpretation

Canals will be infected for some time before

a
periapical radiolucency becomes evident

At least 3 - 4 months

Absence of a radiolucency does NOT imply

the
absence of an infected root canal system

Jansson et al 1993
Radiographic Interpretation

Radiolucency Inflammation

+ +
-
Tube Shift Techniques

Vertical Shift
Increased angle
Decreased angle

Horizontal shift
Mesial
Distal
Tube Shift Techniques

Vertical Shift
Increased angle
Decreased angle
Tube Shift Techniques

Vertical Shift
Increased angle
Decreased angle
 Tube Shift Techniques

Vertical Shift

Decreased angle
elongates the image
NO diagnostic value
NO practical value
=
 Tube Shift Techniques

Vertical shifts

Increased angle
15 vertical shift
Modified parallel technique
Provides more apical detail and definition
Occlusal views
Esp. useful for trauma diagnosis
Root Fractures & Lateral Luxation
Root Fractures
 Lateral Luxation

Periapical Occlusal
Occlusal
 Tube Shift Techniques

Horizontal shifts
Mesial
Distal

Used to separate objects that are otherwise

superimposed over each other
Can help to indicate the 3rd dimension
Mesial Distal

Straight View
 Straight View

Mesial Distal
 Straight View

Mesial Distal
=
=
Mesial

Distal
Endodontic Treatment Radiography/
Working Radiography
Nygaard-stby Frame
 Endodontic Working
Radiography
Lower Posterior
Teeth
Endodontic Working
Radiography
 Endodontic Working
Radiography
Upper Posterior
Teeth
 Endodontic Working
Radiography
Upper Anterior
Teeth
 Endodontic Working
Radiography
Lower Anterior
Teeth
 Endodontic Working
Radiography

Dunvale Snapex Kit

Snapex Kit
Snapex Kit

Parallel Technique

Modified Parallel Technique

Snapex Kit
Anterior Teeth
Snapex Kit
Posterior Teeth
Snapex Kit
Snapex Kit
 Snapex Kit

Upper Posterior Lower Posterior

Teeth Teeth
 Snapex Kit

Upper Posterior Lower Posterior

Teeth Teeth
Processing
Proper darkroom organization, film
handling, and adherence to the time and
temperature method of film processing
play important roles in producing films of
high quality.
 Digitalization of Ionizing
Radiation

Allowed:
Image enhancement
Storage
Retrieval
Transmission of images to remote sites
in a digital format.
Digital imaging systems
require:
1- An electronic sensor or detector.
2- An analog-to-digital converter.
3- A computer.
4- A monitor or printer for image display.
 Direct digital systems have
three components:
1- The radio component consists of a high-
resolution sensor with an active area that is
similar in size to conventional film.
2- The visio portion, consists of a video monitor
and display-processing unit.
3- The graphy, a high-resolution video printer
that provides a hard copy of the screen image.
 The advantages
1- Radiographic images are obtained
immediately.
2- Radiation exposure is reduced from
50% to 90%, compared with
conventional film-based radiography.
 The disadvantages:

1- Their high initial cost.

2- Potential for reduction in image quality when
compared with conventional radiography.
3-Inflexible film (sensor)
 Safety and Regulations

The ionizing radiation (protection of

persons undergoing medical examination
and treatment):
Patient: The radiation dose should be
minimum
The cone should point away from the
patients body and gonads
Use a protective lead apron(0.25mm)thick
Any one in the room who is not required
for examination should be excluded
 Safety and Regulations
Operators and other Staff:
Exposure : is the amount of radiation in an
area to which the patient is exposed.
Dose: is the amount of radiation absorbed per
unit mass of tissue at a particular site.
Staff exposure to radiation should be closely
monitored using film Badges
Film Badge For Measuring
radiation dose
1. The operator must stand at least 2m from
the tube and the patient and outside the
primary beam.
2. The operator should never hold the film, the
tube housing or the patient during
exposure.
3. When not in use the x-ray machine should
be disconnected.
 Cone Beam Computed Tomography
(CBCT)
Cone Beam Volumetric
Tomography (CBVT)

Since 1980s
2000 approved by
FDA
 1.What is CBCT and how does it work?
Principals of CBCT: What is it?

CBCT is a 3-D radiographic tool that allows us

understand the maxillofacial complex and the
special relationship of anatomic structures.

Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP: Accuracy of three-dimensional measurements using CBCT. Dentomaxillofac Radiol 2006:35;410-416.
CBCT

CBCT utilizes a cone shaped

x-ray beam and an area
detector that acquires a full
volume of images in a single
rotation, with no need for
patient movement.
High Contrast Imaging Low Contrast Imaging
Faster Slower
Less Expensive More Expensive
Lower Dose Higher Dose
Higher Noise Lower Noise
Isotropic Anisotropic
X=YZ Voxel
X=Y=Z Voxel

CBCT Spiral CT
 Cone-beam Units

NewTom 3G by AFP Galileos by Sirona MercuRay by Hitachi

I-CAT by ISI 3D Accuitomo Iluma by IMTEC

by J. Morita
Principals of CBCT: VOXEL and Resolution
A voxel (VOlume piXEL),
represents a quantity of 3D
data similar to a pixel
representation in 2D data.
Simulated bone defects in
acrylic blocks and the
human mandible proved
that CBCT is an accurate CBCT Spiral
CT
way to measure osseous
lesion size and volume

Pinsky H, Dyda S, Pinsky RW, Misch KA, Sarment DP: Accuracy of three-dimensional measurements using CBCT. Dentomaxillofac Radiol 2006:35;410-416.