IntraoperativeUseofCBCTforIdentificationandLocalizationof … · 2019. 7. 30. · 2.Cases Presentation 2.1.Case1. An 83-year-old female was referred for evalu-ation and treatment

Case ReportIntraoperative Use of CBCT for Identification and Localization ofCalcified Canals: A Clinical Technique

Spyros Floratos1 and Maria-Elpida Miltiadous2

1Department of Endodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA2Department of Endodontics, School of Dentistry, University of Athens, Athens, Greece

Correspondence should be addressed to Maria-Elpida Miltiadous; [email protected]

Received 8 September 2017; Accepted 31 October 2017; Published 27 November 2017

Academic Editor: Jiiang H. Jeng

Copyright © 2017 Spyros Floratos and Maria-Elpida Miltiadous. +is is an open access article distributed under the CreativeCommons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.

Localization of calci2ed canals has always been a challenge in the 2eld of endodontics.+e following report of three cases describesa technique for the identi2cation and negotiation of obliterated canals by use of cone beam computed tomography (CBCT)intraoperatively. Canal ori2ces could not be found clinically in all three cases. Gutta-percha points were placed and compacted atthe position where the canal ori2ces were estimated to be. Intraoperative CBCT was taken, and the distance between the gutta-percha points and the canal ori2ces was calculated at all planes of space in the 2rst two cases. In the third case, only one canalori2ce could be identi2ed due to obliteration of the other canals.

1. Introduction

Cone beam computed tomography (CBCT) producesthree-dimensional scans of the dentition, the maxillofacialskeleton, and the relationship of anatomic structures. End-odontic applications of CBCT include diagnosis of periapicalbone defects [1], assessment of internal and external rootresorption [1], detection of vertical root fractures [2], visu-alization and localization of perforations [3], identi2cation ofroot canals, and treatment planning of surgical and complexcases such as invaginated teeth [4, 5].

+e size of the 2eld of view (FOV) can vary amongdi@erent CBCT scanners from 3 to 4 cm up to 20 cm [6].Typically the resolution of large FOV images is lowercompared to that of small size FOV [7]. For endodonticpurposes, the FOV should be limited to the region of in-terest; that is, the FOV should encompass the tooth (or teeth)under investigation and its surrounding structures [8].

+e intraoperative use of CBCT for the assessment andmanagement of calci2ed canals has recently been reported[9]. When canals are identi2ed but are subjected to calci-2cation, intraoperative CBCT has been shown to be usefulfor assessing the extent of calci2cation, thereby contributingto determining the proper sequence of the treatment [9].

Recently, intraoperative use of limited FOV for intra-appointment identi2cation and localization of calci2ed ca-nals was recommended [10]; however, a clinical techniquefor the exact localization of the calci2ed canal has not beenreported. In the present study, gutta-percha (GP) points areused intraoperatively as markers, and the distance betweenthe marker and the patent canal ori2ce is calculated at allplanes of space. A case is also presented where the sametechnique was performed but not all canal ori2ces could beidenti2ed as they were obliterated.

2. Cases Presentation

2.1. Case 1. An 83-year-old female was referred for evalu-ation and treatment of her right mandibular second pre-molar. Clinical examination revealed pain on percussionand palpation. Periodontal probings were within normallimits, and there was nomobility.+e tooth was an abutmenttooth, and there was an attachment on the crown for a re-movable partial denture. +e patient’s general practitionerreported previous intraoral swelling on the buccal side ofthe tooth and administered antibiotics (Augmentin 625mgthree times per day for 1 week). Radiographic examinationrevealed canal obliteration and a periapical radiolucency of

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the tooth (Figure 1(a)). +e patient’s medical history in-cluded bisphosphonates per os (Fosamax 70mg once perweek for 10 years). A diagnosis of pulp necrosis andsymptomatic apical periodontitis was established. +e pa-tient was o@ered all treatment options including root canaltreatment with or without replacement of the prostheticrestoration or extraction of the tooth, and she decided tohave root canal treatment through the crown as she did notwant to have a new prosthetic restoration. +e patientprovided written consent for the treatment plan.

After anesthesia with 4% septocaine with 1 : 100,000adrenaline (Ubistesin Forte, 3M ESPE, Seefeld, Germany) andrubber dam isolation (Hygenic Dental Dam, ColteneWhaledent, Langenau, Germany), an access cavity throughthe crown was prepared. +e pulp chamber was presentedwith calci2cation, and no canal ori2ce could be identi2edunder magni2cation. Ultrasonic preparing was performed atthe depth of the preparation in an attempt to locate the canalori2ce, but it was not successful. Following that, a 0.5mm indiameter GP point was placed and compacted at the depth ofthe preparation where the canal ori2ce was estimated to be(Figure 1(b)). A cotton pellet moistened with sodium hy-pochlorite was placed in the access cavity, and the tooth was

temporarily sealed with 4mm of Cavit G (3M ESPE, Seefeld,Germany). +e patient was referred for limited FOV CBCTofthe area of the tooth (Morita 3D Accuitomo 170, J. MoritaMFG Corp., Irvine, CA, USA).+e coronal view of the CBCTrevealed that the canal ori2ce was located 1.46mm buccallyand coronally to the GP point (Figure 1(c)). At the secondvisit, temporary 2lling materials were removed and ultrasonicpreparing was performed buccally to the GP point at theposition indicated by the CBCT. A microopener No. 10/.04(Dentsply Maillefer, Tulsa, OK, USA) was introduced into anopening located along the buccal wall, and the canal locationwas con2rmed using an apex locator (Root ZX II, J. MoritaMFG Corp., Irvine, CA, USA). Root canal preparation wascarried out using an endodontic rotary instrumentationsystem (RaCe, FKG Dentaire SA, La Chaux-de-Fonds,Switzerland) up to a 40/.04 2le. Sodium hypochlorite 2.5%was used for copious irrigation. +e canal was 2lled with GPand epoxy sealer (AH Plus, Dentsply Maillefer, Tulsa, OK,USA) using vertical compaction. +e access cavity along withthe space created lingually with ultrasonic preparing was sealedwith composite resin, and a postoperative radiograph wastaken (Figure 1(d)). It was not possible to recruit the patientfor a yearly recall due to her advanced age.

(a) (b)

(c) (d)

Figure 1: Treatment sequence of tooth 45. (a) Preoperative radiograph. (b) Intraoperative radiograph with gutta-percha point. (c) Coronalview of intraoperative CBCT with gutta-percha point. (d) Postoperative radiograph.

2 Case Reports in Dentistry

2.2.Case 2. A 47-year-old female was referred by her generalpractitioner for evaluation and retreatment of her rightmandibular 2rst molar. Clinical examination revealed nosymptoms. Periodontal probings were within normal limits,and there was no mobility. Radiographic examinationrevealed previous root canal treatment with silver points anda periapical radiolucency of the tooth. Mesial canals wereobliterated and not visible (Figure 2(a)). +e tooth was re-stored with a composite resin buildup. +e patient’s medicalhistory was noncontributory. A diagnosis of previous rootcanal treatment with asymptomatic apical periodontitis wasestablished. +e patient was informed that conventional rootcanal retreatment followed by a crown was the best option.+e patient consented to the treatment plan.

After anesthesia with 4% septocaine with 1 : 100,000adrenaline (Ubistesin Forte, 3M ESPE, Seefeld, Germany)and rubber dam isolation (Hygenic Dental Dam, ColteneWhaledent, Langenau, Germany), the coronal restorationand all root canal 2lling materials were removed from themesiolingual and distal canals, but the ori2ce of the mesio-buccal canal could not be located clinically under the dentaloperatingmicroscope. Ultrasonics were used to treph along theisthmus area at a position where the ori2ce of the mesiobuccalcanal was estimated to be. After trephing a 1mm deep grooveat the mesiobuccal canal position, the ori2ce could not belocated. A GP point was placed and compacted at the depth ofthe groove (Figure 2(b)). Following that, a cotton pelletmoistenedwith sodiumhypochlorite was placed, and the accesscavity was temporarily sealed with 4mm of Cavit G (3M ESPE,Seefeld, Germany). +e patient was referred for limited FOVCBCT (Morita 3D Accuitomo 170, J. Morita MFG Corp.,Irvine, CA, USA). +e axial view of the CBCT revealed thatthe canal was located 0.5mm buccally to the GP point,and calci2cation was evident (Figure 2(c)). Furthermore, thecanal seemed to be patent 2mm apically to the GP point(Figure 2(d)). +e sagittal view of the CBCT revealed that theori2ce of the mesiobuccal canal was located 0.5mm mesiallyto the GP point (Figure 2(e)). At the second visit, temporary2lling materials were removed, and ultrasonic preparing wasperformed buccally and mesially to the GP point. A micro-opener No. 10/.04 (Dentsply Maillefer, Tulsa, OK, USA) wasintroduced into an opening located at the estimated distanceaccording to the CBCT, and the presence of the canal wascon2rmed using an apex locator (Root ZX II, J. Morita MFGCorp., Irvine, CA, USA). Root canal preparation was carriedout using an endodontic rotary instrumentation system (Race,FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) up toa 35/0.4 2le. Sodium hypochlorite 2.5% was used for copiousirrigation. +e canal was 2lled with GP and epoxy sealer (AHPlus, Dentsply Maillefer, Tulsa, OK, USA) using warm verticalcompaction.+e access cavity was sealed with composite resin,and a postoperative radiograph was taken (Figure 2(f)). +epatient was recalled yearly for clinical and radiographic follow-ups. At two-year follow-up, the tooth was asymptomatic, andperiapical healing was observed radiographically (Figure 2(g)).

2.3. Case 3. A 55-year-old male was referred for evalua-tion and treatment of his right maxillary third molar. +e

referring prosthodontist reported that the tooth hadsymptoms on biting and made an access cavity and placeda temporary restoration as an emergency treatment. +etooth would be used as an abutment tooth for a 2xed partialdenture. Clinical examination revealed a temporary resto-ration on the tooth and no symptoms upon percussion orpalpation. Periodontal probings were within normal limits,and there was no mobility. Radiographic examinationrevealed canal obliteration and no apparent periapical ra-diolucency of the tooth (Figure 3(a)). +e patient’s medicalhistory was noncontributory. A diagnosis of asymptomaticirreversible pulpitis was established. A written consent wasgiven by the patient for endodontic treatment of the tooth.

After anesthesia with 4% septocaine with 1 : 100,000adrenaline (Ubistesin Forte, 3M ESPE, Seefeld, Germany)and rubber dam isolation (Hygenic Dental Dam, ColteneWhaledent, Langenau, Germany), the coronal restorationwas removed, and an access cavity was prepared. +e pulpchamber was presented with calci2cation, and no canal or-i2ces could be identi2ed clinically under the dental operatingmicroscope. Ultrasonic preparing was performed in an attemptto locate the canal ori2ces, but it was not successful. Followingthat, two GP points were placed and compacted where theori2ces of the mesiobuccal and palatal canals were estimatedto be (Figure 3(b)). A cotton pellet moistened with sodiumhypochlorite was placed in the access cavity, and the tooth wastemporarily sealed with 4mm of Cavit G (3M ESPE, Seefeld,Germany). +e patient was referred for limited FOV CBCTof the tooth (Morita 3D Accuitomo 170, J. Morita MFGCorp., Irvine, CA, USA). +e axial view of the CBCTrevealedthat the palatal canal ori2ce was located at the GP placed onthe palatal position whereas the mesiobuccal canal was lo-cated buccally to where the respective GP point was placed(Figures 3(c) and 3(d)). At the second visit, temporary 2llingmaterials were removed, and ultrasonic preparing was per-formed according to the information from the CBCT. By useof a microopener No. 10/.04 (Dentsply Maillefer, Tulsa, OK,USA), the palatal canal ori2ce was found and con2rmed usingan apex locator (Root ZX II, J. Morita MFG Corp., Irvine,CA, USA). +e ori2ces of the mesiobuccal and distobuccalcanals could not be located. Root canal preparation of thepalatal canal was carried out using an endodontic rotaryinstrumentation system (Race, FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) up to a 40/0.4 2le. Sodium hypo-chlorite 2.5% was used for copious irrigation. +e canal was2lled with GP and epoxy sealer (AH Plus, Dentsply Maillefer,Tulsa, OK, USA) using warm vertical compaction. Prepara-tion of a post was made on the palatal canal. +e access cavitywas temporarily sealed with cotton pellet and Cavit G, anda postoperative radiograph was taken (Figure 3(e)). +e toothwas followed up for a month and remained asymptomatic.After that, the patient was referred back to the prosthodontist.

3. Discussion

Calci2c metamorphosis or calci2cation is a pulpal responseto trauma characterized by rapid deposition of hard tissuewithin the canal space [11]. In most cases, calci2cation ap-pears to be severe coronally, tapering o@ towards the root

Case Reports in Dentistry 3

(a) (b)

(c) (d)

(e) (f)

(g)

Figure 2: Treatment sequence of tooth 46. (a) Preoperative radiograph. (b) Clinical picture of gutta-percha point at the estimated position ofthe ori2ce of the mesiobuccal canal. (c) Axial view of intraoperative CBCTwith gutta-percha point. (d) Axial view of intraoperative CBCT2mm apically to the gutta-percha point. (e) Sagittal view of intraoperative CBCTwith gutta-percha point. (f) Postoperative radiograph. (g)Radiograph at two-year follow-up.


apex [12]. Teeth with severe pulp calci2cation and root canalobliteration can complicate the access cavity preparation androot canal identi2cation and negotiation, thus leading tounnecessary dentin removal and iatrogenic mishaps such asperforations. In this study, ultrasonic preparing of the den-tinal structure was performed, and GP points were placed atthe point where the canal ori2ce was estimated to be. Fol-lowing that, a limited FOV CBCT was taken, and the GPpoint appeared as a radiopaque marker on the CBCT.Resilon points (RealSeal, SybronEndo, Amersfoort, Neth-erlands) could also be used as they are more radiopaque thanGP. In order for the GP point to be visible, it should be atleast 0.5mm in diameter. If a permanent coronal restorationis present on the tooth (e.g., amalgam and crown), then theGP point should be placed 2mm apically to the CEJ;

otherwise, its position will be diOcult to visualize because ofthe scattering caused by the coronal restoration. +e tech-nique described allows for a measurement of the distancebetween the GP marker and the point where the canal isvisible. +is leads to a more accurate estimation of the canalopening in the clinical situation. As the resolution of thecomputed tomography visualization is enhanced, a limitedFOV scan will probably reveal di@erent levels of calci2cationall along the canal in the near future. Based on the radio-pacity of di@erent levels of calci2cation, an estimation of thepoint whether the canal is patent will probably be possible.

Di@erent ways to locate canal ori2ces have been reportedin the literature. +e use of illumination and magni2cationprovided by the dental operating microscope leads to easierand safer identi2cation of canal ori2ces [13]. Knowledge and

(a) (b)

(c) (d)

(e)

Figure 3: Treatment sequence of tooth 18. (a) Preoperative radiograph. (b) Intraoperative radiograph with gutta-percha points. (c) Axialview of intraoperative CBCTwith both gutta-percha points. (d) Axial view of intraoperative CBCTwith mesiobuccal gutta-percha point. (e)Postoperative radiograph.

Case Reports in Dentistry 5

understanding of the anatomy and color di@erences of thecanal chamber Poor can assist the clinician in the identi2-cation of canal ori2ces [14]. Other aids to locate root canalsinclude staining the chamber Poor with 1% methylene bluedye, additional preoperative radiographs from di@erent di-rections, looking for canal bleeding points, and performingthe sodium hypochlorite “champagne bubble” test [15].

+e intraoperative use of CBCT in complicated end-odontic cases can assist the clinician in ensuring a saferprocedure and a more predictable treatment outcome.However, the use of ionizing radiation should always complywith the principle of ALARA (As Low As ReasonablyAchievable) in order to minimize the patients’ exposure toradiation [16]. +erefore, clinicians must take into consid-eration the e@ective dose and imaging quality of variousimaging techniques and optimize all the diagnostic in-formation provided by lower radiation conventional ra-diographs before turning to CBCT.

In the cases reported in our study, conventional peri-apical radiographs and the dental operating microscopecould not provide suOcient information on the location ofcalci2ed canal ori2ces. +erefore, the intraoperative use ofCBCT was necessary and proved to be vital in successfullylocating the calci2ed canal ori2ces. However, a maxillarythird molar case is also reported where the buccal canalswere completely calci2ed and could not be located evenwith the intraoperative use of CBCT. A limited FOV wasused, thus reducing the e@ective dose to the patient andproducing higher resolution images. Additional research onthe intraoperative applications of CBCT in endodontics andtheir impact on the treatment outcome will be needed.

Conflicts of Interest

+e authors declare that there are no conPicts of interestregarding the publication of this article.

References

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[3] H. Shemesh, R. Cristescu, P. R. Wesselink, and M.-K. Wu,“+e use of cone-beam computed tomography and digitalperiapical radiographs to diagnose root perforations,” Journalof Endodontics, vol. 37, no. 4, pp. 513–516, 2011.

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[7] B. Hassan, M. E. Metska, A. R. Ozok, P. van der Stelt, andP. R. Wesselink, “Detection of vertical root fractures inendodontically treated teeth by a cone beam computedtomography scan,” Journal of Endodontics, vol. 35, no. 5,pp. 719–722, 2009.

[8] S. Patel, C. Durack, F. Abella, H. Shemesh, M. Roig, andK. Lemberg, “Cone beam computed tomography inendodontics–a review,” International Endodontic Journal,vol. 48, no. 1, pp. 3–15, 2015.

[9] R. L. Ball, J. V. Barbizam, and N. Cohenca, “Intraoperativeendodontic applications of cone-beam computed tomogra-phy,” Journal of Endodontics, vol. 39, no. 4, pp. 548–557, 2013.

[10] American Association of Endodontists and American Acad-emy of Oral and Maxillofacial Radiology, “AAE and AAOMRjoint position statement: use of cone beam computed to-mography in endodontics 2015 update,” Journal of End-odontics, vol. 41, no. 9, pp. 1393–1396, 2015.

[11] American Association of Endodontists, Glossary ofEndodontic Terms, American Association of Endodontists,Chicago, IL, USA, 2015.

[12] W. J. van der Meer, A. Vissink, Y. L. Ng, and K. Gulabivala,“3D computer aided treatment planning in endodontics,”Journal of Dentistry, vol. 45, pp. 67–72, 2016.

[13] M. De Carvalho and M. Zuolo, “Ori2ce locating with a micro-scope,” Journal of Endodontics, vol. 26, no. 9, pp. 532–534, 2000.

[14] P. Krasner and H. Rankow, “Anatomy of the pulp-chamberPoor,” Journal of Endodontics, vol. 30, no. 1, pp. 5–16, 2004.

[15] L. Smadi and A. Khraisat, “Detection of a second mesiobuccalcanal in the mesiobuccal roots of maxillary 2rst molar teeth,”Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,and Endodontology, vol. 103, no. 3, pp. e77–e81, 2007.

[16] J. Brown, R. Jacobs, E. Jaghagen et al., “Basic training re-quirements for the use of dental CBCT by dentists: a positionpaper prepared by the European Academy of DentoMax-illoFacial Radiology,” DentoMaxilloFacial Radiology, vol. 43,no. 1, pp. 1–7, 2014.


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IntraoperativeUseofCBCTforIdentificationandLocalizationof … · 2019. 7. 30. · 2.Cases Presentation 2.1.Case1. An 83-year-old female was referred for evalu-ation and treatment