Wei Fan ,DDS MSc ,PhD,* Bing Fan,DDS MSc ,PhD

James L gutmann,DDS ,PhD ,FACD,FADI* and Mingwen Fan, DDS

JOE volume 34, number 10, October 2008

Presented by :
Francis Prathyusha
 Why x-ray ?

 Successful root canal treatment is highly dependent on

through management of root canal anatomy.
 Radiographs are reliable clinical method of determining
canal anatomy .
 Canal anatomy, canal length, quality of obturation , bone
pathology can be identified and monitored
 Standard intra oral radiograph using silver halide film is
used widely.
Disadvantages :
 Exposure to radiation
 Complicates radiographic assessment – radiographs
may differ in
1. Brightness
2. Contrast
3. Acquisition geometry
 Time consuming
 Cannot manipulate
 Storage of chemicals
 Direct digital systems

 Dawn of the digital era in dental radiography came in

1987 when the first digital radiography system called
Radiovisiography, was launched in Europe by the
French company Trophy Radiologie.
 The inventor of this system was Dr. Francis Mouyen.
He invented a way to employ fiber optics to narrow
down a large x-ray image onto a smaller size that could
be sensed by a Charge Coupled Device (CCD) image
sensor chip.
Fundamental Principles of Digital Radiography
 Digital radiography refers to a method of capturing a
radiographic image using a sensor, breaking it into an
electronic pieces, and presenting and storing the image using
a computer.
 In stead of having an analog radiographic image on a film, in
digital imaging the sensor is used to receive the analog
information and through analog-to-digital converter (ADC)
to convert it to a digital image that is an array of picture
elements called pixels, with discrete gray values for each one.
 Special software is used to store and manipulate the digital
image in the computer. The image is displayed within
seconds or minutes on the computer screen in front of the
clinician and the patient/client..
 Equipment
• X-radiation source

• Intra oral sensor

1. Charge-coupled device (CCD)
2. Complementary metal oxide semiconductor/active pixel sensor
(CMOS/APS)
3. Charge injection device (CID)
• Computer
Note:
 Intraoral sensor is composed of a silicone
chip and a layer that surrounds it. A layer
above the sensor chip is the scintillator
(material that emits light when particles
traverse it), which converts x-ray energy into
light and directs it towards the top layer of
the chip that is more sensitive to light than x-
rays. Top layer of the chip then releases
electrons that form the image and send them
onto the well in the lower portion of the chip.
The energy in each well is then read and
digitized with an A/D (analog to digital)
converter during the read-out process.
Advantages
 Ease and speed of use
 Reduction in time between exposure and image
interpretation.
 Less radiation to patient
 Elimination of chemical waste hazard
 Ability to digitally manipulate the captured image
 Ability to copy and duplicate without loss of image quality
 Colourization , as well as manipulation with contrast,
sharpness, image orientation and pseudocolour alteration
 Less physical storage space required
 Easy in recording and rapid storage and retrieval
Disadvantages
 Cost effective
 Sensors are the weak part of the system due to their
relative rigidity and thickness
 Sensors are not universal and interchangeable
between different systems.
 Digital sensors can’t withstand heat sterilization,
therefore they require complete coverage with
disposable plastic sleeves
 Digital radiographs have legal issues because of
their potential for fraudulent use
 Digital subtraction radiography
DSR
 The efficiency of RVG system lies primarily in the identification of image
features buried in back ground of normal anatomic structures.
 Reduction of background noise can be achieved by DSR – which eliminates
the identical image regions in series of radiographs obtained in the same
exposure position and at different time intervals.
 Subtraction radiography is a very sensitive method, because it cancels out
the anatomical noise

Note:

Anatomical noise are the structures that are in the image,

but are not influenced by the pathology that has to be
detected. The irregular trabecular pattern, for instance, will
influence the detectability of bone lesions.
 Changed anatomic structures – stand out clearly
 Unchanged anatomic structures–eliminated

Confused ?????

Image was made This image was The subtraction -reveals

immediately after made one month areas of bone loss in
extraction of a maxillary later black and bone
molar deposition in white .
 Contrast medium in DSR

 To change the radiopacity of some anatomical

structures before DSR
 Many methods used to introduce a water soluble
radiographic contrast medium
1. Injecting the medium in to canal
2. Placing the teeth under a vacuum to pull the
medium in to the canal irregularities
 MICRO CT SCAN
USE
 Evaluate the canal shapes or cross section of teeth
 Diagnose or evaluate the location and size of
periradicular lesion
 Determining morphologic changes before and after
the instrumentation.
 Images obtained could be reconstructed by using
specialized software.
 C shape canal

 The C refers to distinct pulp chamber anatomy

that contains one or multiple canals connected
by a slit or fin.
 Mandibular 2nd molars
 It commonly extends from the M-Li extent of the
chamber to the D-Li, but can be the opposite (M-
B to D-B w/ the C inverted).
 Study
 The purpose of this study was to
investigate the ability of DSR to reveal
anatomic features of c shape canal system
in mandibular second molars with the aid
of intra radicular contrast medium
 MATERIALS AND METHODS
 30 mand.molars – fused roots + deep lingual groove on the
root surface
 Stored in 10% formalin solution
 Scanned with µCT 20(scanco medical , bruttisellen, Switzerland)
From crown to apex at0.5mm intervals.
 3 dimensional canal configuration of each tooth was
reconstructed by using 3D doctor software.( able soft-ware
corp,,lexingotn,MA)
 Referred as a gold standard for assessment of subsequent
canal image reading
 AFTER SCANNING
 Pulp chamber accessed – engine driven fissure bur
 Unroofed with an Endo Z bur(dentsply surrey ltd, UK) to gain
the unimpeded entry to the canals and to prevent
cutting on the chamber floor.
 Pulp extirpation- fine barbed broach
 Teeth soaked in 5% of NaOCL solution – 30 mints
 Canals irrigated – 20ml distilled water
 Jet of water from apical foramen indicated patency
 Without visible jet of water not then canals were
instrumented with No.20 light speed ( light speed technology inc
,San Antonio ,TX)
 20ml -5% Naocl and 20ml distilled water
 IMAGING
 Roots were covered with sticky wax to seal the
canals
 Teeth were put onto the same radiographic device
 RVG digital images taken with mandible plates in
the same way .
 The vacum device was used – 76% compound
meglumine distrizoate( xudong haipu pharmaceutical Co Ltd)
 Now RVG images were taken
 Imaging
 During exposure- position should be strictly kept
unchanged
1. Teeth
2. Bone plates
3. X-ray tube
4. RVG charged- couple device.
 X-ray exposure time – 0.16 sec
 A 4mm wide step wedge made of aluminum 1100
was fixed onto the jig 3mm above the occlusal
surface of the teeth as the reference standard of
radiographic density in all images
Hmmmmmmmmmm…
 Questions running in your mind

 Where is the wedge

 Where is the tooth
 Where are the bony plates
 Position???
An illustration of the radiographic device

Aluminum wedge

Radiograph
X ray tube or CCD
Mandibular
bone plates

Charge-coupled device (CCD)

This is one of the most common image receptors in digital
radiography, an old technology and is used in many other
devices like fax machines, video cameras, microscopes
and telescopes. The CCD is a sensitive to x-rays or light, it
is a solid-state detector that contains a silicone chip with an
electronic circuit embedded in.
 Imaging

 The step wedge – 10 steps with 2mm as step span

 All images were stored in a comp
 Images before and after - overlapped and subtracted
 Subtraction by software 3D doctor
 All DSR images and buccal lingual reconstruction
canal images based on CT scanning were classified
by 3 categories.
 TYPES

Type I merging Type 2 Type 3 asymmetrical

symmetrical
 Classification based on
DSR images & µCT reconstruction
Observation methods Type 1 Type 2 Type 3

DSR 11 11 8

Reconstruction 12 9 9
 The kappa value, which was subject to the U test for
significance at p= 0.05, was calculated to be 0.85,
 The classification based on reconstructed images were
used as the standard to evaluate the sensitivity (se) and
specificity ( Sp) of DSR image construction
 Results were subjected to the wilcoxon statistical test
 The statistical significance was considered at p<0.05
 RESULTS
 The results based on DSR images and
reconstruction
 There were no significance differences
 Se and Sp of DSR images of type 1
DSR Reconstruction total
classification
Type 1 Type 2

Type 1 11 0 11

Non-type 1 1 18 19

total 12 18 30

 High Se and Sp
 Only one tooth with a reconstructed type 1 canal image was
classified as non type 1 or type 2 on DSR images.
Se and Sp of DSR images type 2
DSR recons Total

Type 2 Non type 2

Type 2 9 2 11

non Type 2 0 19 19

Total 9 21 30

 DSR based type 2 has high Se and Sp

 Two teeth with reconstructed non type 2 (type 1 & 2 )
canal images was classified as type2 on DSR images
 Se and Sp of DSR images in type3
DSR reconstrcu Total

Type 3 Non type 3

Type 3 8 0 8

Non type3 1 21 22

Total 9 21 30

 Se and Sp are high

 Only 1 tooth with reconstructed type 3 canal image
was classified as non type 3 ( type2).
 DISCUSSION
 Identifying the potential complexity of the canal
anatomy is a major pre requisite for successful canal
treatment.
 Complicated morphology – image super imposition of
hard tissue surrounding it.
 CT scan diagnose the canal anatomy -But the
dissolution of the image is not yet high enough to show
irregular or fine canal and
 Exposure to relatively high dosage of x ray radiation .
 Discussion

 The contrast medium enhance s the radiopacity of target

tissue images against surrounding tissues.
 Intra radicular contrast medium improved canal
identification even when image superimposition existed
 The identification was lacking when compared with
reconstructed images
 DSR applied to get better image
 Discussion

 DSR has 2 requirements

 Contrast variation in serial images
 Strict repetition of serial positions
 DSR is still a 2 dimensional- angulations
 Eg: Reco type 3 – 1 tooth – DSR type 2
 Cleaning should be proper – distribution of medium
 Eg: Reco type 1 – 1 tooth – DSR type 2
Resolution :
 Complete emptying of tissue debris from canal via
irrigation and dissolution
 Using more effective method of introducing and
distributing the medium.
 CONCLUSION
 Some of the most important benefits this technology
offers include patient education, time efficiency,
reduced exposure to radiation and environmentally
friendly set up. Although DSR has been applied in
medical and dental areas - Assessing augmentation
of alveolar bone crest , the variation of periapical
pathosis, canal resorption the application and
related evaluation of DSR in canal anatomy
identification , especially in C shape canal system
have not been yet explored

DSR IS A POWERFUL TOOL FOR DENTAL PRACTICE