Friday, February 17, 2012

Finding Missed Canals Using Cone Beam Computed Tomography (CBCT)

We have had lots of discussion regarding the use of CBCT in endodontic diagnosis and treatment planning. CBCT is the future of endodontics. 3D imaging as an adjunct to 2D imaging is superior to 2D imaging alone. The ability to evaluate a tooth in a sagittal and axial plane (in additional to the traditional coronal view of standard radiographs) provides valuable information that will lead to the preservation of teeth by improved endodontic treatment, endodontic retreatment and endodontic surgery.

There will be many who think this statement is over the top. However, I would compare the advent of focus-field, high resolution CBCT to the introduction of the operating microscope in endodontics. While there was initial resistance to adoption of the microscope, and still some continued resistance by a few in our specialty, the microscope has undoubtedly improved the quality of endodontic care. CBCT is the same. There will be some who argue that they don't need it, however, it undoubtedly will improve the quality of endodontic care and help preserve teeth.

As an example of the benefits of CBCT in improving endodontic diagnostics and treatment, I present the follow 4 cases. Each case completed by a different endodontist. All of these clinicians are highly skilled endodontists using microscopes. However, in each case, canals were missed and the patient continued to have issues. They have different stories, but all ended up in our office for an evaluation or second opinion. I have included myself as one of these 4 endodontists. (One of the cases is my own)


#31 is the symptomatic tooth. Two canals have been filled to a good length.

CBCT slice of mesial root shows the two mesial canals join and exit at one apex.

This is another slice of mesial roots showing the buccal filling and the ML missed canal. The sagittal view tells us where to look when we retreat this tooth. Axial view also demonstrates the missed canal. Using these two views, when I retreat this tooth, I will know where to explore without perforating the root.
This particular endodontist refunded the patient and preferred that we retreat the tooth at our office.


This root canal was treated by another endodontist and then retreated after symptoms failed to resolve. She came to Superstition Springs Endodontics for a second opinion. The obturated roots look filled to an ideal length.

CBCT reveals a missed MB#2 canal. Blue outline shows an axial slice of the MB root. The pear-shaped root outline reveals the missed canal.

The sagittal view also shows the MB#1 canal is off center of the long axis of the root. A lesion into the sinus cavity is noted. Note the distinct MB lesion visible in the CBCT. I explained to the patient that it would be the other endodontist would likely retreat this tooth at no charge, but this patient has elected to retreat the tooth in our office.


This root canal done in 2007. Recently became symptomatic.

CBCT shows lesion on MB and DB with elevation of floor of sinus. This corresponds to chronic sinus issue patient has been dealing with.

Cross sectional slice (axial) through the MB root shows the missed MB#2 canal. The pear-shaped or figure-8 shape of the MB root reveals the missed MB#2 canal.

This sagittal view shows that the missed MB#2 canal is actually a separate root. While the roots are fused all the way down, it has its own apex.

The CBCT is a map for retreatment. It tells us exactly where to look to find the missing canal.
This patient returned to her previous endodontist for retreatment.

I know each one of these endodontists, and they all do excellent work. I confidently suggested to each of these patients that they return to their previous endodontist for evaluation. Using the CBCT map for retreatment, I am confident each one of these endodontists will find the additional canal. One endodontist is retreating at no charge, one endodontist is refunding patient and she will have treatment in our office, and the third patient did not want to return and has elected to pay for retreatment in our office.

CASE #4 - My Missed Canal Found with CBCT

I completed this RCT in Nov 2011. Palatal lesion seemed to improve, but patient symptoms returned. In this particular case, I found only 2 canals. After extensive searching under the microscope, I determined that this must be one of those tricky 2 rooted Mx molars. Since symptoms returned, we took CBCT to see if I missed anything.

CBCT reveals that I did miss a DB canal. However, looking closely at the axial view, my assumption that this is a 2 rooted molar was correct. The palatal and DB roots were fused as one. Sagittal view shows the missed DB canal. Axial view shows the missed DB as well. The CBCT is now a map for retreatment.

As explained, the axial and sagittal view provided by CBCT is invaluable. More information provides for better treatment. This post should demonstrate the level of complexity of molar endodontic therapy even with the use of the operating microscope and the benefit of 3D imaging over 2D imaging alone.


Pedro Martins said...

Sorry about the offtopic, but do you use film x-rays or do you use any sort of digital x-ray sensor? I ask that because I found your images very sharp (and with lots of contrast and definition) when compared with my old Kodak RVG 5000.
Thank you! Congratulations for the blog!

Vlad Tismensky, DDS said...

Great post Dr. Hales! I must say, that every case shown reminded me of my own cases or evaluations that were pretty much identical. I do not have a cone beam imaging in my office at this time and when necessary I do send a patient to get an image taken. But as quality of endo becomes better and general dentists do more of it, endodontists will have to step it up a notch, we are going to need it more often!
Question 1: If you cant find canals for example and need a cone beam, do you charge a patient?
Question 2: Do you think that cone beam will become standard imaging for endodontists?

The Endo Blog said...

Dr. Tismensky,

Thanks for your kind comments. To answer your question...
1. If I can find a canal during procedure, I usually include the CBCT as part of the RCT fee or do it at a reduced fee.
2. Yes, I believe CBCT is comparable to the microscope. I think it completely changes the quality of care. However, just like microscopes, there will likely be some unwilling to see the benefit and will fight it.

Anonymous said...

I'm just not sold on this yet. I believe those canals could be found using the microscope...especially the cases you yourself did not start.

Anonymous said...

My fear with CBCT is the radiation dose. When weighing up the risks and benefits of saving a tooth the radiation dose must play a role. How much radiation is justified to find a canal? I am an Endodontist and my wife is a Palliative care nurse so we regurlaly have these sort of mealtime discussions. A good operating microscope will find most canals without the radiation.
Excellent blogs. Love the whole site. A fantastic learning tool, great to read peoples comments too. Thank you.