3D Image Clinical Cases
Endodontics

Thinking ahead. Focused on life.

Contents
Endodontics ............................................................................................................. 3
Tooth Fracture .................................................................................................... 15
Lateral Luxation .................................................................................................. 18
Internal Resorption ............................................................................................ 19
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 DentistryHans-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

2

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 theroot 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 canals merge apically – very unusual – and withadequate time committed to the irrigation process that allowed a threedimensional 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.

3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).
Accuitomo CT imaging revealed a different story, allowing me to tread carefully
during treatment (Figs. 6B.). The ﬁrst bit of important information was that thistooth unusually had only three canals (Fig. 6C).
Fig. 6A

Fig. 6B

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 patient’s tooth from a broken rotaryﬁle, it revealed a severe canal curvature – in the normally-hidden buccal plane(Fig. 6E). Treatment, as a result was quick and sure with an exceptional (sorry,but it’s true) result (Fig. 6E).

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

4Endodontics Case 3
a./b. The ﬁrst examination. A 20 year
old male. The chief complaint was thediscoloration of the crown of # 9 and slight
pain. External resorption from the palatal
aspect and LEO were found. He had anexperience of subluxation of the involved
tooth 3 years ago.
Fig. ac./d. CBCT appearances. c: sagittal. d: axial.
The root resorption start from the cervicalarea 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. bf. The trimmed # 9. 2–3 mm of the apex
was cut off and the apical foramen was
retro-ﬁlled with light curing GIC. The crownportion was cut off obliquely.

Fig. cg. 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 andthe suture was removed 4 days after thesurgery. No other splinting was performed
any longer.

Fig. dh. 3 weeks after the surgical extrusion andjust after the restoration of the crown withcomposite in a direct method.
i. A radiograph two months after the surgery.
j. A radiograph 1 year post op.
Fig. eFig. fFig. gk. A clinical appearance 1 year post op.

Fig. k

Fig. hl. CBCT appearance 1 year post
op. The PDL space and the
buccal alveolar bone is nicely
preserved. No resorption isobserved. Interesting is that
the PDL is formed over the
retro-ﬁlling materials.

Fig. iFig. jFig. lThe case in this page was provided by Dr.Tsukiboshi
taken with the 3D Accuitomo.

5Endodontics Case 4a.-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 theSchneiderian membrane is thickened due to inﬂammation.
The cause was considered to be the inappropriate canaltreatment of the mesial root.
a. Periapical radiographb. Clinical viewc. Coronal view of the mesial rootd. Coronal view of the palatal roote. Coronal view of the distal root
f. Sagittal view of the mesal and distal roots

Fig. aFig. cFig. dFig. bg. During treatment.
Only the mesial root was retreated endodonticallyusing a microscope.
Fig. eFig. fh. Periapical radiograph six months later.
i.-l. CBCT appearance six months later. The sinus bone hascome back and the Schneidarian membrane looks normal.

Fig. gFig. hFig. iFig. jFig. k

Fig. lThe case in this page was provided by Dr.Tsukiboshi
taken with the 3D Accuitomo.

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

# 10

8 months

2year.9m#98 months

2year.9m

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

7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
percha 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 ofthe 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.

8Endodontics Case 7

The periapical radiograph shows awell corticated, 3–4 mm periapicalradiolucency onto the second molar.
The tooth is endodontically treated
and the endodontic ﬁlling material ishomogenous, well condensed, andreaching the apex.
On the cone beam CT, the periapicallesion presence is conﬁrmed withthe presence of a severe vertical periodontal bone loss reaching the apexof the tooth in the form of what wecall “endo-perio” communication. Thisﬁnding was not seen on the periapicalﬁlm due to the projection of the buccal
and palatal thick cortical bones overthe image of the periodontal lesion.

The case in this page was provided by Marcel Noujeim DDS MS
taken with the 3D Accuitomo.

9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 image shows an
air-ﬁlled, healthy, maxillary sinus and aperiapial 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 waspresent at the ﬁrst molar, but was
uncertain about its extent.

The Accuitomo images showed alesion with a very large extent in all
directions. It has caused a break-downof both the buccal and palatal cortical borders. It extends into the lateralpart of the nasal cavity and the lower
part of the maxillary sinus where areaction 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 ofthis could be anticipated from intraoral
radiographs alone.

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

11Endodontics Case 10
Although having taken several intraoral radiographs, an endodontist 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 palatalroot, but also that a second palatal root exists in which the root canal has notbeen treated. In addition, a lesion is seen in the interradicular area between thelatter and the mesiobuccal root. The lesion at the buccal roots extends into thelower part of the maxillary sinus in which a thickening of the mucosa can be
seen.

The case in this page was provided by Hans-Göran Gröndahl 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 notenderness 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 theLR6 as the crown margin was subgingival. The LR7 predictably did not respondto the electric pulp test. The periapical radiograph (Fig. A ) revealed widening at
the periapex of the LR7 with no other signs of pathology.

Fig. AThe sagittal slices of the microCT scan(Fig. B) however clearly showed a
4 mm circular lesion associated withthe apex of the distal root of the LR7.
The reason why this could not be seenon the periapical radiograph could beunderstood from the coronal slice (Fig.
C) that shows the lesion positioned
entirely in cancellous bone and not
involving the cortical plates – theprerequisite for visibility on a standard
periapical radiograph. Furthermore theanatomy 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 inpain following the procedure. With the scan, treatment was initiated immediately
in the LR6 and the pain quickly eased. Endodontic treatment of the LR7 whencompleted, was done without further damage in an attempt to locate a second
mesial canal (Fig. E).
Fig. EThe 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 wereincompletely 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 theappearance of a ﬁstula 18 months later conﬁrmed regression and reinfection.

Fig. F

Fig. J

Fig. G

Fig. HA 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 ofa recurrent periapical lesion with a satisfactory orthograde root ﬁlling would be buccal
approaching periapical surgery with lesion curettage, apicectomy and possibly an apicalretrograde 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 ofthis 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. K

Fig. OIn this case a decompression procedure was carried out and a plastic drain was placed
buccally (Figs. 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 showedshrinkage of the lesion and full reformation of bothbuccal and palatal plates (Figs. P & Q). Although buccal
approaching periapical surgery with lesion curettage andapicectomy was now possible, with the lesion asymptomatic and good healing it was decided to leave andobserve further on the basis that marsupialisation of atrue cyst might have occurred and contamination at theroot apices were no longer an issue. A further review
was scheduled for 1 year.

Fig. I

Fig. P

Fig. L

Fig. QThe 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. Lackof 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 havebecome 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 fractureof the apical part of the right medial
incisor.
In the left medial incisor, an almost
horizontal root fracture is seen. In boththe apical and the coronal fragments,
the pulp is almost completely obliterated.

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

15

Tooth Fracture Case 2

Fig. 8This 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 crownof # 13. Interestingly,
the fracture does
not extend into theenamel, but appears
to end at the area ofthe dento-enamel
junction. There isalso widening of theperiodontal ligament
space along the fracture line. Finally, thereis thickening of the
mucoperiosteal liningof the ﬂoor of the left
maxillary sinus consistent with maxillarysinusitis, that mostprobably is unrelated
to the dental disease
described above.

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

16

Tooth Fracture Case 3This 67 year old female patient underwent endodontic treatmentof 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 theperiodontal ligament space around the apical area of all the rootsof # 3 and 4.
However, Accuitomo scan reveals a longitudinal root fracture of themesiobuccal root of # 4 and extensive bone loss at the whole extent
of the mesio-buccal root and destruction of the buccal cortex of themaxilla at the area (Fig. 7).

Fig. 6

Fig. 7The case in this page was provided by Dr. Sotirios Tetradis
taken with the 3D Accuitomo.

17

Lateral Luxation CASE 1
BeforeLateral luxation and follow-up
with CBCT.
A 23 year old female. Two
central incisors are involved
with lateral luxation, which isvery difﬁcult to diagnose withconventional methods, but iseasily revealed with CBCT.
One year 3 months follow-up
result with CBCT has shown
the complete healing.

#8#9

1 year and 3 months later#8#9The 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-Göran Gröndahl 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 acervical 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 justabove the osseous crest of bone, dictating extraction.
Typically, treatment of this tooth would have been instituted, wasting the patient’s time and money when thetooth 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

Fig. 3Fig. 3 shows the periapicalradiograph of a 54 year old
asymptomatic male patient.
Panoramic and periapicalradiographs taken during aroutine dental examination,
reveal enlargement of thepulpal cavity of teeth # 22 and23, consistent with internal
resorption. However, theseradiographs do not offer any
information regarding theextent of the resorption andthus do not aid in the treatment planning (i. e. endodontic
treatment vs. extraction) of
the patient. Clinical examination was unremarkable.
An Accuitomo scan delineatedthe 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 theinternal and presence of external root resorption the teeth
were deemed unrestorable.

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-Göran Gröndahl Professor emeritus, DDS, PhD
taken with the 3D Accuitomo.

23

Diagnostic and Imaging Equipment
Treatment Units
Handpieces and Instruments
Endodontic Systems
Laser Equipment
Laboratory Devices

Distributed by
J. Morita Europe GmbH
Justus-von-Liebig-Str. 27a
63128 Dietzenbach
Germany
T +49. 6074. 836 0, F +49. 6074. 836 299
www.morita.com/europe
Developed and manufactured by
J. MORITA MFG. CORP.
680, Higashihama Minami-cho, Fushimi-ku,
Kyoto, 612-8533
Japan
T +81. 75. 611 2141, F +81. 75. 622 4595
www.jmorita-mfg.com

Subject to technical changes and errors. JME EN PUB 2035 1216 *3.