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,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.
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..
• 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)
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 xrays. 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.
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
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
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
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
Image was made immediately after extraction of a maxillary molar
This image was made one month later
The subtraction -reveals areas of bone loss in black and bone 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 (MB to D-B w/ the C inverted).
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
Referred as a gold standard for assessment of subsequent
canal image reading
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
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
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
Questions running in your mind Where is the wedge Where is the tooth
Where are the bony plates
An illustration of the radiographic device
X ray tube
Radiograph 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.
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.
Type I merging
Type 2 symmetrical
Type 3 asymmetrical
Classification based on DSR images & µCT reconstruction
Observation methods Type 1 Type 2 Type 3
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
The results based on DSR images and
reconstruction There were no significance differences
Se and Sp of DSR images of type 1
DSR classification Reconstruction Type 1 Type 2 total
Non-type 1 total
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 Type 2 Type 2 non Type 2 9 0 Non type 2 2 19 11 19 Total
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
Type 3 Type 3 Non type3 Total 8 1 9 Non type 3 0 21 21 8 22 30
Se and Sp are high
Only 1 tooth with reconstructed type 3 canal image
was classified as non type 3 ( type2).
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 .
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
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
Complete emptying of tissue debris from canal via
irrigation and dissolution Using more effective method of introducing and distributing the medium.
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
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