3D IMAGE CLINICAL CASES - ENDODONTICS

Contents

n ENDODONTICS........................................................................ 3
n TOOTH FRACTURE............................................................... 15
n Lateral luxation............................................................ 18
n INTERNAL RESORPTION.................................................... 19
n ENAMEL DROP..................................................................... 23
Supervised by Yoshinori Arai,DDS, PhD
Professor Nihon University
School of Dentistry
Clinical images are provided by:
(Listed in alphabetical order)
L. Stephen Buchanan, DDS, FICD, FACD
Alan H. Gluskin, DDS, Professor and Chair
Department of Endodontics
University of the Pacific
Arthur A. Dugoni School of Dentistry
Hans-Goran Grondahl, DDS, PhD (Odont Dr)
Professor emeritus
Department of Oral and Maxillofacial Radiology
Institute of Odontology
The Sahlgrenska Academy
Gothenburg University, Gothenburg, Sweden
Dr. Richard S. Kahan
Director of Endodontic Courses
Honorary Clinical Lecturer
Eastman CPD
University College London (UCL)

Marcel Noujeim, DDS, MS

Oral and Maxillofacial Radiology
University of Texas Health Science Center at San Antonio
Erkki Tammisalo
Emeritus professor of Oral Radiology
Tomodent, Private Laboratory of Oral Diagnostic Imaging
Turku, Finland
Sotirios Tetradis, DDS, PhD
Professor and Chair
Section of Oral and Maxillofacial Radiology
UCLA School of Dentistry
Mitsuhiro Tsukiboshi, DDS, PhD
Private Practice, Tsukiboshi Dental Clinic, Aichi, Japan

3D Accuitomo

Veraviewepocs 3D

ENDODONTICS CASE 1
The patient presented below suffered from an
irreversibly inflamed pulp in tooth #2, confirmed
by prolonged thermal responses to cold and heat.
Conventional radiographs revealed a fused root
structure with little or no information about the root
canal anatomy (Fig. 5A).
(Fig. 5A)

(Fig. 5B)

(Fig. 5C)
Accuitomo imaging revealed that this molar had only three canals (reassuring), and
that the two buccal canals merged in the apical third and bifurcated again (Figs. 5B
& C). The post-operative conventional radiograph shows this anatomy treated out,
with pre-informed anatomic knowledge (no looking for a fourth canal, knowing that
the buccal canal merge apicallyvery unusualand with adequate time committed
to the irrigation process that allowed a three-dimensional obturation of the apical
bifurcation of the canal system after the confluence (Fig. 5D).

(Fig. 5D)
-The case in this page was provided by Dr. L. Stephen Buchanan
taken with the 3D Accuitomo.

ENDODONTICS CASE 2
The patient presented with an irreversibly inflamed pulp in tooth # 3, confirmed by
cold and heat testing (prolonged responses). Conventional radiographs revealed
mesio-buccal root anatomy that was very curved, with the disto-buccal and palatal
root anatomy appearing fairly straight (Fig. 6A).

(Fig. 6A)

Accuitomo CT imaging revealed a different story, allowing me to tread carefully during treatment (Figs. 6B.). The first bit of important information was that this tooth
unusually had only three canals (Fig. 6C).
(Fig. B)

(Fig. 6C)

(Fig. 6D)
The second piece of very important information was that the curvature of the
mesiobuccal canal was truly awe-inspiring (Fig. 6D). The third piece of information saved my self respect and the patients tooth from a broken rotary file, it
revealed a severe canal curvaturein the normally-hidden buccal plane (Fig. 6E),.
Treatment, as a result was quick and sure with an exceptional (sorry, but its true)
result (Fig. 6E).

(Fig. 6E)
-The case in this page was provided by Dr. L. Stephen Buchanan
taken with the 3D Accuitomo.

ENDODONTICS CASE 3
a. b. The first examination. A 20 year old male.
The chief complaint was the discoloration of
the crown of #9 and slight pain. External resorption from the palatal aspect and LEO were
found. He has an experience of subluxation of
the involved tooth 3 years ago.
(Fig. a)

c. d. CBCT appearances. c: sagittal. d: axial. The

root resorption start from the cervical area on
the palatal aspect and invaded into the dentin.
e. The extracted #9 for the surgical extrusion.
Note the large lacuna on the palatal aspect.

(Fig.b)

f. The trimmed #9. 2-3mm of the apex was cut

off and the apical foramen was retro-filled with
light curing GIC. The crown portion was cut off
obliquely.

(Fig.c)

g. Just after the surgical extrusion. The root

was rotated 180 degree. The fixation was only
with the suture strings. Surgical dressing was
applied for the first two days and the suture
was removed 4 days after the surgery. No other

(Fig.d)

splinting was performed any longer.

h. 3 weeks after the surgical extrusion and just
after the restoration of the crown with composite in a direct method.
i. A radiograph two months after the surgery.
(Fig.e)

j. A radiograph 1 year post op.

(Fig.f)

k. A clinical appearance I year post op.

(Fig.g)

(Fig.k)

(Fig.h)

l. CBCT appearance 1 y. pot op. The

PDL space and the buccal alveolar
bone is nicely preserved. No resorption is observed. Interesting is that
the PDL is formed over the retrofilling materials.

(Fig.i)

(Fig.j)

(Fig.l)
-The case in this page was provided by Dr.Tsukiboshi
taken with the 3D Accuitomo.

ENDODONTICS CASE 4
a. ~f. Before treatment. A 46 year old female. The chief
complaint is pain around #3.
The bone of the sinus floor is badly resorbed and the
Schneiderian membrane is thickened due to inflammation.
The cause was considered to be the inappropriate canal
treatment of the mesial root.
a: Periapical radiograph
b: Clinical view
c: Coronal view of the mesial root

(Fig.a)

d: Coronal view of the palatal root

e: Coronal view of the distal root
f: Sagittal view of the mesal and distal roots

(Fig.c)

(Fig.d)

(Fig.b)

g. During treatment. Only the mesial root was retreated

endodontically using a microscope.

(Fig.e)

(Fig.f)

h. Periapical radiograph six months later.

i ~ l: CBCT appearance six months later. The sinus bone

has come back and the Schneidarian membrane looks
normal.

(Fig.g)

(Fig.h)

(Fig.i)

(Fig.j)

(Fig.k)

(Fig.l)
-The case in this page was provided by Dr.Tsukiboshi
taken with the 3D Accuitomo.

ENDODONTICS CASE 5
Apicoectomy and follow-up
with CBCT
A 41 year old female. #9 and
#10 suffer LEO and apicoectomy was indicated.
3mm of each apex was cut off
and the bony defect was filled
with Bio-oss after the retrofillings. The healing of the
involved teeth was followed
up with CBCT.

# 10

8 months

2year.9m

#9

8 months

2year.9m

-The case in this page was provided by Dr.Tsukiboshi

taken with the 3D Accuitomo.

ENDODONTICS CASE 6

The periapical and panoramic radiographs show an acceptable endodontic

treatment reaching the slightly lateral apex of tooth # 10. The endodontic
filling lateral appears to be doubled, giving the impression of the presence
of two canals. Ill-defined periapical radiolucency is noted slightly on the
distal aspect of the apical third.
Cone beam images show that the gutta percha is perforating the facial
aspect of the root and the buccal cortex. Some gutta perch is found in the
canal but it is not reaching the apex.
Periapical radiograph is a 2d presentation of a 3d object; it collapses all the
structures in the examined area in one plane. The image of the gutta percha
is projected over the image of the root giving the impression of an acceptable treatment.

-The case in this page was provided by Marcel Noujeim DDS MS

taken with the 3D Accuitomo.

ENDODONTICS CASE 7

The periapical radiograph shows a

well corticated, 3-4mm periapical
radiolucency onto the second molar.
The tooth is endodontically treated
and the endodontic filling material is
homogenous, well condensed, and
reaching the apex.
On the cone beam CT, the periapical
lesion presence is confirmed with the
presence of a severe vertical periodontal bone loss reaching the apex
of the tooth in the form of what we
call endo-perio communication. This
finding was not seen on the periapical film due to the projection of
the buccal and palatal thick cortical
bones over the image of the periodontal lesion.

-The case in this page was provided by Marcel Noujeim DDS MS

taken with the 3D Accuitomo.

ENDODONTICS CASE 8
The patient was complaining of diffuse
pain over the left maxilla. Conventional
radiographs did not reveal patholigical changes in the periapical region of
premolars and molars. A Veraviewepocs
3D scan shows an air-filled, healthy,
maxillary sinus and a periapial lesion at
the apex of the buccal root of the first
premolar.

Palatal side

Buccul side

-The case in this page was provided by Dr. Erkki Tammisalo

taken with the Veraviewepocs 3D.

10

ENDODONTICS CASE 9

An endodontist had taken several

images of the upper right molar region on a patient who presented with
pain. He could see that a lesion was
present at the first molar, but was
uncertain about its extent.

The Accuitomo images showed a lesion with a very large extent in all directions. It has caused a break-down
of both the buccal and palatal cortical
borders. It extends into the lateral
part of the nasal cavity and the lower
part of the maxillary sinus where a
reaction is seen in the mucosa. The lesion also involves the root system of
the second molar and gets very close
to the unerupted third molar. None of
this could be anticipated from intraoral radiographs alone.

-The case in this page was provided by Hans-Gran Grndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

11

ENDODONTICS CASE 10
Although having taken several intraoral radiographs, an endodontist still felt uncertain about
the conditions at the upper right second molar
from which the patient still felt some pain after
an endodontic treatment had been completed.

The Accuitomo images show lesions at the two buccal roots and at a palatal
root, but also that a second palatal root exists in which the root canal has not
been treated. In addition, a lesion is seen in the interradicular area between
the latter and the mesiobuccal root. The lesion at the buccal roots extends into
the lower part of the maxillary sinus in which a thickening of the mucosa can
be seen.

-The case in this page was provided by Hans-Gran Grndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

12

ENDODONTICS CASE 11
Clinical examination of the LR5, LR6 and LR7, revealed no abnormalities with
no tenderness to palpation at the buccal and lingual root apices and no tenderness to percussion of any of the teeth. Vitality testing could not be carried out
at the LR6 as the crown margin was subgingival. The LR7 predictably did not
respond to the electric pulp test. The periapical radiograph (Fig. A ) revealed
widening at the periapex of the LR7 with no other signs of pathology.

(Fig. A)
The sagittal slices of the microCT
scan (Fig. B) however clearly showed
a 4mm circular lesion associated with
the apex of the distal root of the LR7.
The reason why this could not be
seen on the periapical radiograph
could be understood from the coronal
slice (Fig. C) that shows the lesion
positioned entirely in cancellous
bone and not involving the cortical
plates the prerequisite for visibility
on a standard periapical radiograph.
Furthermore the anatomy of the root
canals in the LR7 could be visualized
with there being clearly one mesial
and one distal canal (Fig. D).

(Fig. D)

(Fig. B)

(Fig. C)
Without the microCT scan provided by the Veraviewepocs 3D, an attempt
would have been made to find another canal in the LR7, as there was no reason
to treat the LR6. Significant damage to the root of the tooth would have occurred before the search would have been abandoned, and the patient would
still have been in pain following the procedure. With the scan, treatment was
initiated immediately in the LR6 and the pain quickly eased. Endodontic treatment of the LR7 when completed, was done without further damage in an
attempt to locate a second mesial canal (Fig. E).

(Fig. E)

-The case in this page was provided by Dr. Richard S. Kahan

taken with the Veraviewepocs 3D.

13

ENDODONTICS CASE 12
A 24 year old male patient attended 2 years following root canal therapy of his upper right central and lateral incisors (UR1 and UR2) with a draining buccal fistula
(Fig. J). The teeth had been originally traumatised aged 10 and the apices were
incompletely formed. On presentation with periapical infection aged 22 (Fig. F),
the orthograde root canal treatments that were carried out had initially involved
calcium hydroxide therapy followed by obturation with MTA apical plugs (Figs. G
& H). Initial follow up at 6 months suggested some resolution (Fig. I ), but the appearance of a fistula 18 months later confirmed regression and re-infection.

(Fig. J)
(Fig. F)

(Fig. G)

(Fig. H)

A microCT scan of the lesion using the Veraviewepocs 3D (Figs. K & L) revealed the true size
of the lesion with both buccal and palatal plate perforations. The usual treatment of a recurrent periapical lesion with a satisfactory orthograde root filling would be buccal approaching periapical surgery with lesion curettage, apicectomy and possibly an apical retrograde
seal. However, if this would have been carried out with such a lesion, soft tissue ingrowth
from the palatal side would resist bony repair. True repair of a lesion of this size would
require either a membrane on one side if the lesion to resist soft tissue ingrowth, or decompression followed by conventional surgery. Whichever is chosen, neither would have been
immediately considered in a case such as this, and therefore, poor bone healing would have
followed on from a standard surgical approach without the benefit of the microCT scan.

(Fig. M)

(Fig. N)

(Fig. I)

(Fig. K)

(Fig. O)

In this case a decompression procedure was carried out and a plastic drain was placed
buccally (Fig. M & N) with the patient instructed to irrigate the underlying bony cavity with Corsodyl using a syringe. The drain stayed in place for 2 weeks and was then
removed (Fig. O).
A microCT scan carried out after 6 months showed shrinkage of the lesion and full reformation of both buccal and
palatal plates (Figs. P & Q). Although buccal approaching
periapical surgery with lesion curettage and apicectomy was
now possible, with the lesion asymptomatic and good healing it was decided to leave and observe further on the basis
that marsupialisation of a true cyst might have occurred and
contamination at the root apices were no longer an issue. A
further review was scheduled for 1 year.

(Fig. P)

(Fig. L)

(Fig. Q)
-The case in this page was provided by Dr. Richard S. Kahan
taken with the Veraviewepocs 3D.

14

TOOTH FRACTURE CASE 1

This patient presents with discolored upper medial incisors. Several years
ago he had received a blow to his upper front teeth but had received no
treatment. Lack of symptoms and dental resources made him forget about
his teeth until a dentist in his new home country made him aware of
the discoloration of his upper incisors. At a recent visit to the dentist he
describes that he sometimes has a dull pain in the area of the upper right
medial incisor.
An Accuitomo examination of the upper frontal region demonstrates an
upper right medial incisor with a very wide root canal. This can be seen
in teeth that have become devitalized at an early age. At the apex of this
tooth, a large cystic lesion can be seen. Its borders are not clearly defined
and the surrounding bone is denser than normal. The lesion, thus, has the
appearance of an infected apical cyst.
The examination also
shows a fracture of the apical part of the right medial
incisor.
In the left medial incisor,
an almost horizontal root
fracture is seen. In both the
apical and the coronal fragments, the pulp is almost
completely obliterated.

-The case in this page was provided by Hans-Gran Grndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

15

TOOTH FRACTURE CASE 2

Figure 8
This 48 year old male patient complains of severe pain in the left maxilla that developed after eating. Panoramic (Fig.
8A) and periapical radiographs (Fig.8B) show a possible widening of the periodontal ligament space at the mesial surface of tooth #13. The Accuitomo scan (Fig. 9) clearly reveals an oblique fracture of the root of #13 that extends from the
palatal surface of the root towards the buccal surface of the crown of #13. Interestingly, the fracture does not extend
into the enamel, but appears to end at the area of the dento-enamel junction. There is also widening of the periodontal
ligament space along the
fracture line. Finally, there
is thickening of the mucoperiosteal lining of the
floor of the left maxillary
sinus consistent with maxillary sinusitis, that most
probably is unrelated to the
dental disease described
above.

Figure 9
-The case in this page was provided by Dr. Sotirios Tetradis
taken with the 3D Accuitomo.

16

TOOTH FRACTURE CASE 3

This 67 year old female patient underwent endodontic treatment
of teeth #3 and 4, four weeks ago. Despite the apparent successful
endodontic treatment, the patient reports severe pain in the area. A
panoramic radiograph (Fig. 6) demonstrates widening of the periodontal ligament space around the apical area of all the roots of #3 and 4.
However, Accuitomo scan reveals a longitudinal root fracture of the
mesiobuccal root of #4 and extensive bone loss at the whole extent
of the mesio-buccal root and destruction of the buccal cortex of the
maxilla at the area (Fig.7).

Figure 6

Figure 7

-The case in this page was provided by Dr. Sotirios Tetradis

taken with the 3D Accuitomo.

17

Lateral luxation CASE 1

Before
Lateral luxation and
follow-up with CBCT.
A 23 year old female. Two
central incisors are involved with lateral luxation, which is very difficult
to diagnose with conventional methods, but is easily revealed with CBCT.
One year 3 months followup result with CBCT has
shown the complete healing.

#8

#9

1 year and 3 months later1

#8

#9
-The case in this page was provided by Dr.Tsukiboshi
taken with the 3D Accuitomo.

18

INTERNAL RESORPTION CASE 1

In a symptomless patient with known trauma to her upper left medial incisor several
years ago, the Accuitomo examination shows a severly resorbed tooth. The images demonstrate the clarity with which resorptions now can be studied. Note that the walls of
the pulp still remain and that there is a lack of buccal bone at the middle of the root. In
all likelihood, the origin of this resorption is external rather than internal.

-The case in this page was provided by Hans-Gran Grndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

19

INTERNAL RESORPTION CASE 2

The first image is a traditional periapical film that shows the resorption superimposed over the pulpal space making it very difficult to determine the origin
of the resorptive process.
Is the resorption internal or is it external?
How extensive is the damage to the tooth?
What is the prognosis?

The 3D Accuitomo images make it very clear that we are dealing with a cervical resorption.
The cervical (external) resorption extensively invades tooth #9. The process is
highly destructive, yet it has not invaded the pre-dentin surrounding the pulp.
The 3D images clearly demonstrate a destructive process that makes the prognosis for tooth retention poor.

-The case in this page was provided by Alan H. Gluskin, DDS Professor
taken with the 3D Accuitomo.

20

INTERNAL RESORPTION CASE 3

The patient presented with pain
to palpation over tooth #11. Vitality testing revealed that the tooth
was vital. The conventional preoperative radiograph showed an
unusual appearance of the root
canal space just apical to the CEJ
(Fig. 4A).

(Fig. 4A)
(Fig. 4C)
All periradicular bone appeared to be normal. Accuitomo
imaging revealed (Figs. 4B &C) a large internal/external
resorption defect on the buccal surface of the root just
above the osseous crest of bone, dictating extraction. Typically, treatment of this tooth would have been instituted,
wasting the patients time and money when the tooth was
hopeless.

(Fig. 4B)
-The case in this page was provided by Dr. L. Stephen Buchanan
taken with the 3D Accuitomo.

21

INTERNAL RESORPTION CASE 4

Figure 3
Fig. 3 shows the panoramic
(Fig. 3A) and periapical
(Fig. 3B) radiographs of
a 54 year old asymptomatic male patient. These
radiographs, taken during
a routine dental examination, reveal enlargement of
the pulpal cavity of teeth
#22 and 23, consistent with
internal resorption. However, these radiographs do
not offer any information
regarding the extent of the
resorption and thus do not
aid in the treatment planning (i.e. endodontic treatment vs. extraction) of the
patient. Clinical examination was unremarkable. An
Accuitomo scan delineated
the extent of internal root
resorption in both teeth.
Interestingly, in addition
to the internal resorption,
external resorption at the
cervical area of both #22
and #23 was observed.
Based on the extent of the
internal and presence of
external root resorption the
teeth were deemed unrestorable.

Figure 4

Figure 5
-The case in this page was provided by Dr. Sotirios Tetradis
taken with the 3D Accuitomo.

22

ENAMEL DROP

This young girl presents with pain localized to the upper left first molar region. The accuitomo examination reveals the presence of an enamel pearl in the palatal part of the
interradicular area. There are two palatal roots that become fused as they come close to
the crown forming a crescent shaped curvature in which the enamel pearl is found. The
sagittal image (lower right image) shows the two palatal roots. In the interradicular area,
and surrounding the enamel pearl, a lesion is found. In addition, the apical parts of the
roots are surrounded by a denser than normal bone indicating an inflammatory reaction.

-The case in this page was provided by Hans-Gran Grndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

23

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