How to add multi-modality endodontics, the right CBCT 3D imaging system to benefit your practice and your patients

The standard of care in endodontics is changing dynamically in relation to the technology that is available. Researching and investing in the right technology allows us to seize the full potential to practice the complete spectrum of endodontics.

Professional associations and various authors repeatedly mention CBCT 3D imaging as a new standard. It is a conduit to advancing endodontics, raising our high standards of excellence and providing enhanced comprehensive oral health care to our patients. The right technology allows you to provide proficient diagnosis and guidance to fellow medical and dental professionals.

There has been a rapid influx of 3D imaging machines on the market. Not all machines are right for every practice. There is a wide array of machines, all very different. You need to do the research to determine which one works best for your practice, and know what they offer from the ability to pre-screen medical treatments, to diagnosing pain, to treating special needs patients to implant treatment. 

Multi-Modality Endodontics

Multi-Modality Endodontics (MME) is the use of multi-modality imaging machines to treat endodontic patients. Having the specific strengths of several complementary imaging modalities and software has numerous advantages in assessing and treating patients. We become more comprehensive in aiding our colleagues. Saving our natural dentition is an important task, while diagnosing and treating the surrounding oral facial structures is just as important. A multi modality machine (MMM) allows for 2D imaging, 3D imaging, a true panorex, periapical imaging, and a true “Super Bitewing.” The 3D imaging should have the flexibility to go from large to small volume, but most of all bi-lateral. The imaging modalities should be flexible enough to view any area of the oral maxillary complex, including TMJ and sinus. The software should have an implant library and the capability to place them.

Comprehensive treatment

A good MMM has the capability to render different size 2D and 3D images. If radiation exposure is an issue, the machine should be able to blend a variety of mA/kV and apply them in multiple size 2D or 3D imaging.

Many machines are marketed to a small volume (3 x 5). A versatile MMM is not limited to a restrictive volume. It has the advantage of rendering a small single tooth scan and the ability to do a bilateral or full scan. If the patient has a lifetime of dental restorations or is anticipating work in a future treatment plan, a one-time CBCT scan has many advantages:

• Increased success with treating current endodontic teeth
• Knowledge of all root morphology for future endodontic treatment
• Diagnosing incipient issues, a cost saving to the patient
• Bilateral is more comprehensive for implant placement and guide fabrication. It’s less expensive for the practitioner and patient.
• Less radiation and less time consuming when doing one scan rather than multiple small volume scans

Pre-screening for medical procedures is a simple task with the right MMM. Many physicians look to our office to rule out any major dental issues, especially pertaining to chronic infections. For patients undergoing radiation treatment, Fosamax treatment, cardiac, orthopedic and organ transplant, a bilateral volume is the most efficient rendering to complete. If your 3D machine does only a small volume, you have to take multiple volumes. This adds up to a larger overall radiation dose, with more difficulty quantifying and sending out diagnostic information.

Diagnosing pain

Pain may be acute, chronic, stimulated, un-stimulated, and diffuse or site specific and on first instinct may be odontogenic in origin. Diagnosing non-odontogenic pain falls within MME’s comprehensive treatment. Obtain a broad picture of the target area, and then focus with more detail using a 3D rendering. We have the technology to comprehensively examine patients to assist the general practitioner and patient in a more thorough direction, giving them an end point. From the inception, our profession has based our radiographic interpretation and diagnosing on traditional 2D imaging. With the inception of 3D, lesions and surrounding anatomical structures have a distinct difference. There is a definitive advantage to diagnosing with both capabilities.

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Special needs patients

Children, gaggers, limited opening or complex medical conditions make it difficult to get diagnostic radiographs. The right MMM is invaluable in this area. 3D is great, but not for this. Having a MMM that also can render flexible and specific traditional 2D radiographs is a cost savings for the patient and a practice builder.

A MMM should have:

• Extraoral bitewing (Fig. 11) to capture left and right sides, capture apexes and separate the contacts with no overlap.
• Panorex Adjustable Rate that doesn’t distort the midline, allowing for more diagnostic capability to circumvent radiographs inside the mouth.
• Segmented panorex to target areas of interest and exclude other areas (Figs. 1, 2).
• Interproximal panorex that separates the contacts to enhance the diagnostic capabilities of decay detection as well as the full oral cavity. The radiographic information can be forwarded to the general practitioner after the treatment plan is completed. A cost- and time-effective, beneficial service for the patient and referring doctor.
• I.V. Sedation

Whether your patient is phobic, a gagger, a child or a special needs patient, the ability to take a Super Bitewing and 3D image from your MMM allows for a superior treatment plan. The Bitewing allows for bilateral 2D detail on a large scale for diagnosing. The bilateral 3D rendering allows for anatomic detail of each tooth. Knowing about a torturous, calcified or extra canal before the patient is sedated is beneficial. Both modalities together allow for streamlined pretreatment planning:

• Minimizing the sedation time
• Increasing the safety
• Reducing cost for sedation time
• Non-surgical/surgical endodontics

In years past we would treatment plan a tooth. We now have to think about treatment planning a specific oral-facial area to fit into a long term treatment plan. The standard of endodontic care has increased in relation to the technology now available. The percentage of root canal success has increased because the standard of how we save teeth has increased. With MME, we look at a failing root canal and determine with more precision how to save the tooth. With more exactitude, we can determine if surgical or non-surgical retreatment will provide a greater prognosis. We look at the tooth and surrounding area. We can more accurately predict the ease or difficulty of retreatment, or surgery or if an implant can be placed. If we determine an implant would have a poor prognosis or not be cost effective in an area, more emphasis is put on retreating to save an existing tooth.

Implantology

When retreatment is not deemed feasible, the MME has the anatomical and diagnostic information to continue assisting the referring practitioner to expedite the implant process. The inception of virtual planning and rapid lab fabrication allows the practitioner to treatment plan right from the computer. Bilateral or full scan has the advantage of not rescanning numerous areas multiple times. Especially with guide fabrication, it can become costly.
Now let’s take a look at a few different scenarios.

Case example No. 1

A patient presents with severe swelling, a gagger, or a physical limitation that prohibits the patient from opening to render a traditional 2D PA film (Fig. 2). Instead of taking an entire panorex, we can choose the teeth we want to see. If we feel a 3D image is necessary, from the same machine, we can render a small volume of the exact same area. If we want to compare tooth anatomy on the contralateral side, we can include another target area. This allows us to compare tooth anatomy, position and possible similar treatment history.

Case example No. 2

A patient not experiencing discomfort was sent for a prescreening. The 2D periapical film shows a previous root canal treatment that may have been termed suspicious or uneventful (Fig. 3). The 3D rendering shows a large, well-circumscribed area (Fig. 4).

Case example No. 3

The patient presented with acute pain and a periapical film of tooth No. 31 (Fig. 5). After oral examination, a CBCT was rendered (Fig. 6). Our first inclination was something was wrong with my machine’s image. We look at radiographic lesions in a new perspective. From the same MMM, a traditional 2D panorex was taken to complement and compare bilaterally for diagnosing (Fig. 7).The same machine panorex aided in traditional diagnosing. The 3D image aided with a new diagnostic look to quantify and analyze the extent of the lesion for the surgical intervention. Diagnosis: Ameloblastoma.

Case example No. 4

The patient experienced long-standing chronic intermittent one-sided facial pain and had a history of seven root canals and an apicoectomy, two different bite appliances, a CAT scan and multiple opinions with no resolve (Figs. 8 and 9). From the MME approach, a focused tooth 2D periapical film showed no periapical pathology on the maxilla or mandible. An adjustable small volume 3D CBCT was rendered. No lesions were present so we eliminated periapical pathology, possible root fractures, and sinus as contributory problems. A 3D rendering of the TMJ was completed. A bone fragment was present. The volume was sent to Beam Readers for a full diagnostic review (Fig. 10). MMM allows the endodontist to comprehensively diagnosis and coordinate the treatment team for a more accurate treatment. The patient received a cost and time effective treatment plan.

Case example No. 5

The patient presented for a second opinion for apicoectomy on symptomatic tooth No. 30. A bilateral scan was completed. A distal lingual root was missed. The advantage of a bi-lateral scan reveals the anatomy on the contra-side molar (Fig. 12). The frontal cross sections reveal the prognosis of attempting an apicoectomy. The thickness of bone and the position of the DL root would entail a large amount of the DB root to be removed.

The clear choice was to retreat the tooth conservatively (Fig. 13). Having the right technology benefits the patient and is reflective of how the right technology and diagnosis can save more teeth.

Case example No. 6

The patient presented with pain that persisted after a root canal (Fig. 14). The CBCT’s cross sectional view revealed a furcation fracture causing an odontogenic maxillary sinusitis (Fig. 15). From the cross sectional views, clinicians can plan the extraction and how to prepare the area for an implant. The image can be immediately sent in both 3D and DICOM for study and surgical guide fabrication. A comprehensive MMM has an implant library to place in the scan to aid the referring dentist and educate the patient.

Closing thought

Many CBCT machines are entering the market. Knowing which machine is right for your practice takes some homework. Go beyond the sales person that visits the office. Decide what you want to achieve and how you want to grow your practice. Look to a company and MMM that will grow with the length of time you are in practice. In the long run, it will be more cost effective, intellectually more rewarding and a more complete service for your patients. 

Dr. Brian Trava, DMD, PA, graduated from Lycoming College in 1984 and graduated from the University of Medicine and Dentistry of New Jersey in 1988. He was accepted and finished his two-year post-graduate work in Endodontics from UMDNJ. Dr. Trava started the Hawthorne practice in 1990 and the Ho-Ho-Kus practice in 1993. He was an assistant clinical professor at UMDNJ teaching post-graduate endodontics from 1993 to 2000. He has been voted Top Doc by NJ Monthly from 2005 -2012, and has performed charitable work in Africa with the NBA and honored by the Boys and Girls Club for his work in the community.