Journal of Oral Biosciences 58 (2016) 100–111

Contents lists available at ScienceDirect

Journal of Oral Biosciences

journal homepage: www.elsevier.com/locate/job

Review

Three-dimensional imaging of internal tooth structures: Applications

in dental education
Akiko Kato a,n, Alexander Ziegler b, Michiya Utsumi a, Kimitoshi Ohno c, Takuro Takeichi c
a
Department of Oral Anatomy, School of Dentistry, Aichi Gakuin University, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya, Aichi 464-8650, Japan
b
Institut für Evolutionsbiologie und Ökologie, Rheinische Friedrich-Wilhelms-Universität Bonn, An der Immenburg 1, 53121 Bonn, Germany
c
Department of Fixed Prosthodontics, School of Dentistry, Aichi Gakuin University, 2-11 Suemori-dori, Chikusa-ku, Nagoya, Aichi 464-8651, Japan

ar t ic l e i nf o a b s t r a c t

Article history: Background: Providing comprehensive knowledge of the anatomy of human teeth is one of the basic
Received 30 March 2016 functions of dental education, primarily because a thorough understanding of their internal structure is
Received in revised form one of the prerequisites for any successful clinical intervention. Several techniques have traditionally been
18 May 2016
employed to study and visualize the complex internal organization of human teeth. In contrast to these
Accepted 31 May 2016
invasive techniques, modern imaging systems permit non-invasive analyses of the three-dimensional
Available online 10 June 2016
structure of human teeth. Owing to the relative ease of acquisition, handling, and distribution of the
Keywords: respective data, digital imaging techniques will also significantly influence dental education.
Computed tomography Highlight: In this article, a broad overview of traditional and modern techniques for the visualization of
Endodontics
internal tooth structures is provided. Emphasis is placed on computed tomography systems and their
Additive manufacturing
application in endodontics. In addition, the results derived from a comparison of histology and micro-
Visualization
Teaching computed tomography are presented. Apart from its utility in basic research, digital data can also be
employed to create interactive three-dimensional models that are particularly suitable for teaching purposes.
Conclusion: Non-invasive, three-dimensional imaging techniques, in particular the various modalities of
computed tomography, have ushered in a new era of endodontic studies. Owing to their digital nature, the
results derived from these techniques can not only be easily analyzed and distributed but also be rapidly
integrated into teaching materials. Recent studies as well as the data shown in the present contribution
suggest that digital educational materials lead to an improved understanding of the complex anatomy of
human teeth.
& 2016 The Authors. Published by Elsevier B.V. Japanese Association for Oral Biology. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
2. Traditional methods of analyzing internal tooth structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
3. Three-dimensional imaging techniques permitting non-invasive visualization of internal tooth structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
3.1. Magnetic resonance imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
3.2. Computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
3.3. Spiral computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
3.4. Cone-beam computed tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
3.5. Micro-computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
3.6. Synchrotron-radiation micro-computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4. Endodontic studies using micro-computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.1. Comparative root canal measurements illustrate the precision of micro-computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.2. High-resolution micro-computed tomography in endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.3. Soft tissue imaging using micro-computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.4. Finite element modeling based on computed tomography scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

n
Corresponding author. Tel.: þ 81 52 751 2561; fax: þ81 52 752 5988.
E-mail address: a-kato@dpc.agu.ac.jp (A. Kato).

http://dx.doi.org/10.1016/j.job.2016.05.004
1349-0079/& 2016 The Authors. Published by Elsevier B.V. Japanese Association for Oral Biology. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111 101

5. Potential uses of digital tooth data in dental education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

5.1. Interactive three-dimensional models of human teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.2. Dentistry students and interactive three-dimensional models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.3. Additive manufacturing of three-dimensional human tooth models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.4. Online deposition of three-dimensional tooth data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Ethical approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Conflict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

1. Introduction
A thorough understanding of the anatomy of the human tooth
has always been an important constituent of dentistry, particularly
with regard to teaching purposes [1,2]. In addition, a comprehensive
knowledge of the tooth's internal structure is essential to the suc-
cessful treatment of diseases associated with the pulp cavity [3]. For
over a century, various techniques have been employed to study the
anatomy of the human tooth [4–7]. The findings of these pre-
dominantly invasive methods have had a significant influence on
clinical practice as well as on dental education. However, non-
invasive, digital imaging techniques such as magnetic resonance
imaging (MRI) or computed tomography (CT) presently constitute
the main approach for research involving the three-dimensional
(3D) aspect of teeth. Consequently, interactive 3D models and virtual
training systems based on MRI and CT datasets are becoming more
widely used in the areas of medical and dental education [8–10].
In order to illustrate the significant progress that has been made
in the field of endodontics using modern imaging techniques, the
present article aims to provide an overview of the traditional,
invasive methods used to analyze tooth anatomy and the modern,
non-invasive techniques employed for the visualization of the pulp
cavity. In addition, the application of various CT techniques such as
spiral CT, cone-beam computed tomography (CBCT), or micro-
computed tomography (μCT) for anatomical studies is outlined.
Furthermore, several examples of the accuracy of CT-based techni-
ques as well as advanced applications of these methodologies are
provided. A further section of the article describes how dental
education can directly profit from the techniques initially employed
for more specific research purposes. The present review concludes
by providing an outlook on contributions of digital endodontic data
to the large-scale analyses of internal tooth structures and how such
studies can provide students in dentistry with additional, compre-
hensive learning materials.
2. Traditional methods of analyzing internal tooth structures
In his pioneering work to reconstruct and visualize human tooth
anatomy, Preiswerk [4] employed Wood's metal, an alloy that melts
at a low temperature. His approach was relatively simple: (1) The
tooth is perforated from the occlusal surface down to the pulp
chamber. (2) Then, the tooth is moderately heated until a piece of
Wood's metal placed in a cardboard funnel above the tooth's surface
begins to melt. (3) The funnel then fills with the molten metal,
which flows down into the root canals. (4) Following heat dissipa-
tion, the tooth is dissolved, thus exposing the internal metal cast of
the pulp cavity (Fig. 1a). Only a few years later, Fischer [11] used a
solution of celluloid dissolved in acetone, instead of Wood's metal, to
visualize the pulp cavity. The methods used by Preiswerk and
Fischer can still be successfully used to reproduce the shape of root
canals, but, due to the necessary corrosion of the tooth surrounding
the cast, these techniques do not provide a precise impression of the
relation between the pulp cavity and the mineralized part of the
tooth. In order to circumvent this problem, Okumura [12] used
grinding sections that allowed a more direct investigation of the
relation between the external and internal structure of the tooth. He
created numerous sections from all permanent teeth to describe and
measure several important endodontic parameters, including the
position of the floor of the pulp cavity, the thickness of the pulp
cavity wall, the distance from the cervical line to the furcation area,
the number, size, and shape of root apical ramifications, as well as
the horizontal sectional variations at the level of the root canal
orifice and apical area (Fig. 1b). However, because the study was
presented in Japanese only, Okumura's work was not met with
much international recognition and the approach was therefore not
adopted by other endodontic researchers.
Two years after Okumura's study, Adloff [13] improved
Preiswerk's approach by first injecting molten metal into root
canals, then rendering the studied teeth transparent in order to
investigate the relation between the pulp cavity and the remaining
tissue. Shortly afterwards, Moral [14,15] reported another method,
where hard tissues were also made transparent, but where the
pulp cavity was filled with Indian ink instead of Wood's metal
(Fig. 1c). Using this approach, the author demonstrated, among
other findings, that the frequency of the existence of a fourth root
canal in the mesiobuccal roots of the 100 maxillary molars ana-
lyzed was 63%. Only a few years later, Hess [16] published notable
results on the anatomy of different root canals from a sample
comprising 2800 permanent human teeth. He succeeded in
reconstructing the root canal shape on such a large scale by using a
novel approach that involved filling the teeth with vulcanized
rubber (Fig. 1d). To complement his findings, he made grinding
sections of selected teeth to illustrate the fine structure of the root
canals in their apical region. Hess [5] also conducted experiments
aimed at reproducing the results obtained by Preiswerk and Adloff.
However, his trials largely ended in failure due to cracks in the
dentine that formed during the heating process.
In addition to the invasive techniques employed by these early
researchers, X-ray imaging was soon found to constitute a valuable
approach for elucidating the internal structure of the human tooth.
In his seminal study, Mueller [17] used X-ray imaging to investi-
gate extracted teeth filled with gutta-percha (Fig. 1e). Since then,
extra-oral as well as intra-oral X-ray imaging has been used to
understand variations in the structure of the pulp cavity [18–20].
For example, Pineda and Kuttler [6] as well as Benjamin and
Dowson [21] more recently used X-ray images taken from the
mesiodistal and buccolingual directions to determine the number
of root canals present in teeth with a single or with two roots.
However, multi-rooted teeth such as maxillary molars required the
roots to be cut off and imaged separately in order to avoid
superimposition of the various root canals in the resulting two-
dimensional (2D) X-ray images [6,19]. This impediment meant
that conventional X-ray imaging never became a mainstream
technique in the field of endodontic research.
102 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111

Fig. 1. Overview of techniques traditionally used for the visualization of internal tooth structures. (a) Schematic drawings of Wood's metal replicas of the pulp cavity from
two mandibular molars. Modified from [4]. (b) Schematic drawings of grinding sections of maxillary first premolars. Modified from [12]. (c) Drawings of three Indian ink-
filled mandibular molars cleared using phenol. Modified from [15]. (d) Corrosion casts of the root canals of two maxillary molars made using vulcanized rubber. Modified
from [5]. (e) X-ray images of three maxillary first premolars showing pulp cavities filled with gutta-percha. Modified from [17]. (f) Two views of an epoxy-filled maxillary
second molar cleared using papain. Modified from [18]. (g) Two hematoxylin-filled maxillary second premolars cleared using liquid plastic resin. Modified from [7]. (h) Three
Indian ink-filled semi-transparent mandibular molars cleared using benzoic acid. Modified from [30].

Instead of relying on X-ray imaging, Hirano and colleagues [22],
further advancing the invasive techniques employed by previous
workers, used Indian ink to visualize the root canal shape, but
instead rendered the teeth transparent using silicone oil. A similar
approach was later employed by Barker and colleagues [18] as well
as Carns and Skidmore [23] using epoxy resin replicas (Fig. 1f).
However, because these techniques were complex and time-con-
suming, only a few subsequent studies pursued these approaches.
A significant step forward was later made by Vertucci and col-
leagues [7], who documented a broad morphological variation in
the root canals of 200 maxillary second premolars. These authors
used hematoxylin to stain the fresh pulp tissue, while the teeth
were completely cleared using a liquid plastic resin following
dehydration in alcohol (Fig. 1g). Since then, this approach has
become a standard method in endodontic research, and numerous
reports [24–34] have been published that elucidate root canal
systems using this so-called “clearing technique” (Fig. 1h).
partial or even full destruction of the studied samples and were
not digitized, thus rendering the distribution of the raw data dif-
ficult. The early to mid-1990s then saw the first application of a
computerized, digital approach based on micrographs of grinding
sections. Using diamond and silicon carbide disks, Berutti [35] and
Blašković-Šubat and colleagues [36] cross-sectioned extracted
teeth and photographed these sections using a camera attached to
a stereomicroscope. The individual photographs were then digi-
tized, the shape was manually outlined, and the resulting stacks of
labeled shapes were rendered in 3D using specialized image pro-
cessing software. However, although partly digital, this approach
still required the destruction of the samples under study. With the
improvement of imaging techniques such as MRI or CT, the fully
digital, non-invasive analysis of the internal structure of teeth had
finally become possible.
3.1. Magnetic resonance imaging

MRI is a non-invasive imaging technique based on the principle

3. Three-dimensional imaging techniques permitting non-
invasive visualization of internal tooth structures
As outlined in the previous section, a considerable range of
techniques has been successfully employed to visualize the anat-
omy of human teeth. However, these methods often required the
of nuclear magnetic resonance [37]. The major advantage of this
technique for human diagnostics is the absence of any form of
ionizing radiation. Furthermore, MRI provides excellent soft tissue
contrast without the need for contrast agents. However, hard tis-
sue contrast—of prime importance for studies involving teeth—is
not as good in MRI scans as it is in scans made using X-ray-based
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111 103

Fig. 2. Examples of non-invasive imaging techniques used to study tooth anatomy. (a) Virtual coronal section through an MRI dataset of the head of an adult female at the
level of the mandible. The dataset has an isotropic voxel resolution of 500 μm. (b) Virtual coronal section through a CT dataset of the head of an adult female at the level of
the maxilla. This dataset has an isotropic voxel resolution of 500 μm. Modified from [44]. (c) Comparison of two CBCT datasets of a single human tooth, gathered at 200 μm
(left) and 76 μm (right) isotropic voxel resolution. Modified after [56]. (d) Comparison of µCT and SRµCT datasets of the mandibular molar of a Miocene hominoid primate.
μCT (left) uses a polychromatic X-ray beam, while the X-ray beam in SRμCT (right) is monochromatic, resulting in improved contrast. The isotropic voxel resolutions of this
11.5-mm wide specimen are 20 μm (μCT) and 30 μm (SRμCT), respectively. Modified from [62]. (e) Comparison of absorption contrast (left) and phase contrast (right) imaging
using the molar of an Oligocene eosimiid primate scanned with SRμCT. This 3.2-mm wide specimen was scanned at 6.7 μm isotropic voxel resolution. Modified from [62].

imaging techniques such as CT. Nonetheless, MRI can be success-
fully used to visualize tooth anatomy, in particular if specimens are
analyzed in a hydrated state. Tymofiyeva and colleagues [38]
provide a review of dental studies using MRI. While clinical (i.e.,
human) MRI scanners can usually provide isotropic voxel resolu-
tions of about 500 μm (Fig. 2a), pre-clinical (i.e, small animal)
scanners may permit acquisition of isotropic voxel resolutions
down to 20 μm, depending on the size of the sample and the
magnetic field strength of the scanner [39]. Although not common
practice, endodontic research has already benefitted from using
MRI systems. For example, Tymofiyeva and coworkers [38,40] used
clinical MRI scanners to visualize dental pulp in vivo at isotropic
voxel resolutions down to 112 μm. A comparative study by Gau-
dino and colleagues [41] using MRI and different CT techniques
concluded that MRI is capable of better characterizing soft tissues
and could be applied to the detection of inflammatory or neo-
plastic pathologies at an early stage.
3.2. Computed tomography
In contrast to MRI, 3D data on mineralized tissues can be
rapidly and reliably obtained using the X-ray-based imaging
technique CT. However, due to the nature of this part of the
electromagnetic spectrum, CT methods are invariably associated
with varying degrees of ionizing radiation [42]. Originally devel-
oped in the early 1970s as a medical imaging technique by
Houndsfield [43], CT has now become available at different levels
of resolution [42] and various instruments are being used in
endodontic research, in particular spiral CT, CBCT, μCT, and
synchrotron-radiation micro-computed tomography (SRμCT).
3.3. Spiral computed tomography
Some case reports show that spiral CT (Fig. 2b) can be an
effective tool for validating internal tooth structures [44,45].
However, the isotropic voxel resolutions that can be obtained are
currently limited to about 200 μm, which does not permit the
resolution of finer root canal structures [46,47]. In addition, spiral
CT exposes the patient to a significantly higher radiation dose than
intraoral or panoramic radiography. Consequently, the application
of spiral CT scanners in dentistry is limited [48].
3.4. Cone-beam computed tomography
Owing the above-mentioned limitations associated with spiral
CT and the advantages of CBCT (in particular a reduced radiation
dose), this latter technique is more widely used for diagnostic
purposes in dentistry [48–51]. However, for the application of
CBCT in basic endodontic research, it would be particularly
important to ascertain which root canal dimensions can still be
recognized. In a study using μCT—a technique providing much
higher isotropic voxel resolutions than CT or CBCT—Cheung and
colleagues [52] analyzed the apical anatomy of C-shaped root
canal systems in selected mandibular second molars. Their ana-
lysis showed that the mean values for the longest and shortest
root canal diameter at the apical constriction were 260 and 150 μm
at the mesial as well as 360 and 220 μm at the distal canal,
respectively. Subsequently, Naitoh and colleagues [53] evaluated a
standard CBCT scanner with an isotropic voxel resolution of
100 μm using phantoms of known sizes (i.e., pillars of 100, 200,
300, and 400 μm width). Their study showed that despite its
advertised capability, this CBCT system was not suited to resolve
structures of 100 μm in width. These data also show that the
theoretically achievable isotropic voxel resolution does not
104 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111

Fig. 3. Examples of the 3D visualization of human root canal shape based on μCT datasets. (a) 3D models of six mandibular premolars with multiple root canals. Modified
from [71]. (b) Shaded (above) and semi-transparent (below) 3D volume renderings of the apex of a mandibular second molar with a pronounced C-shaped root canal.
Modified from [52]. (c) 3D reconstructions of two selected root canals (center) from a mandibular molar (left) and corresponding virtual horizontal sections (right). The
different colors illustrate the original root canal dimensions (green) as well as enlargements resulting from preparations using instruments with different sizes (yellow¼ #20,
red¼#30). Modified from [75].

necessarily match the spatial resolution that can be achieved in
practice [53].
In a similar study, Al-Rawi and colleagues [54] compared the
accuracy of CBCT- and μCT-based 3D models of human teeth. These
authors showed that their specific CBCT system did provide
accurate 3D reconstructions of individual teeth at 133 μm isotropic
voxel resolution, but only when a small field of view (6  6 cm)
was selected. However, the latest CBCT apparatuses now permit
scans with isotropic voxel resolutions down to about 75-80 µm
[55,56] (Fig. 2c). Using a scanner with an equally high resolution, a
recent study by Byun and colleagues [57] showed that CBCT data
in conjunction with 3D modeling and additive manufacturing
(AM) can be successfully used in the treatment of formation
anomalies, including internal tooth structures. CBCT has also suc-
cessfully been used in epidemiological surveys of unusual root
morphologies [58–60].
3.5. Micro-computed tomography
which helps to avoid beam hardening (Fig. 2d), and (3) high beam
coherence, which allows phase contrast imaging (Fig. 2e). Using
SRμCT, Tafforeau and Smith [63] demonstrated the first non-
invasive approach for visualizing the microstructure of the tooth
and revealing several aspects of its development, including the
Retzius line periodicity and the presence of the neonatal line. In
addition, SRμCT presently constitutes the reference system for the
study of highly mineralized fossil samples and is consequently
successfully applied in paleoanthropological studies. For example,
Tafforeau and colleagues [64] investigated enamel prisms at an
isotropic voxel resolution of 678 nm through the entire thickness
of dental enamel in primate teeth of living and fossil taxa. How-
ever, due to the relatively small size of the electron particle beam
and the high radiation dose, only extracted teeth and tissues can
be analyzed. Although the number of particle accelerators around
the world is limited, access to these systems is usually free of
charge based on short peer-reviewed proposals.

In contrast to CT and CBCT, μCT was originally developed for

industrial purposes [42,61]. Because μCT systems are equipped
with a micro-focus X-ray source, scans are made at high isotropic
voxel resolutions, sometimes even down to the nanometer scale
[42]. However, due to their technical setup, most μCT systems can
only be used to study extracted teeth or tissues. Please see the
following section for an extended description of the applications
for μCT in endodontic research.
3.6. Synchrotron-radiation micro-computed tomography
SRμCT is a complex technique available at selected particle
accelerators around the world. Like other CT modalities, SRμCT can
be used to non-invasively analyze a large variety of structures, but
in particular those that are difficult to study using μCT [62]. SRμCT
is characterized by a number of aspects not available on other CT
systems: (1) high beam intensity for rapid data acquisition at very
high spatial resolutions, (2) monochromatization of the beam,
4. Endodontic studies using micro-computed tomography
Due to the fact that μCT permits non-invasive analyses of tooth
anatomy, a considerable number of endodontic studies presenting
results based on this methodology have been published since the
mid-1990s (e.g. [65–68]). In particular, the descriptions of complex
root shapes such as isthmuses or 3D curvatures as well as mea-
surements of parameters like dentine thickness or canal width
have profited from the properties presented by μCT scans [69,70].
This technique has also been successfully used to analyze teeth
with multiple root canals (Fig. 3a), to investigate molar roots as
well as root canals that display unusual topologies (Fig. 3b), and
has contributed to the development of novel root canal prepara-
tion instruments through the evaluation of the amount of canal
wall area prior to and following preparation (Fig. 3c) [52,71–75].
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111 105

Fig. 4. A comparison between μCT and histological data with regards to root canal dimensions. These representative data were gathered using the tip of the mesiobuccal root
of a maxillary left first molar. The inset shows a volume rendering of the entire, intact tooth and the approximate level of section (dashed black line). The values derived from
the root canal measurements are provided in Table 1. Numbers 1–5 indicate identical root canals. (a) Virtual section through a μCT dataset with 46 μm isotropic voxel
resolution. (b) Histological (grinding) section with 120 µm thickness through the same tooth made following μCT scanning. (c) Schematic root canal drawing depicting the
orientation of the primary tooth axes used for measuring (x ¼ mesiodistal, y¼ buccolingual).

4.1. Comparative root canal measurements illustrate the precision of
micro-computed tomography
In order to demonstrate the accuracy of μCT-based imagery, a
virtual 2D section through a 3D μCT dataset (Fig. 4a) was com-
pared with an approximately 120 μm thick grinding section made
at exactly the same position (Fig. 4b). To this end, the mesiobuccal
root of an extracted maxillary first molar was used. Prior to his-
tological sectioning, the entire tooth was scanned at an isotropic
voxel resolution of 46 μm using an SMX-225CT μCT scanner (Shi-
madzu Corp., Kyoto, Japan). The virtual 2D section was chosen
using an interactive 3D model for orientation (Fig. 4, inset). The
same 3D model was also used to orient the tooth prior to the
sectioning of the mesiobuccal root. The grinding section at a 2-mm
distance coronal to the apical area was then generated after the
μCT scanning. The root was sectioned using an IsoMet Low Speed
Saw (Buehler, Lake Bluff, IL, USA). The section was lapped on a
grinding machine using 3 μm aluminum oxide, ultrasonicated, and
finished using a 1 μm alumina suspension. This face of the section
was then fixed to a microscope slide under pressure using UV
Resin (Logitech Ltd., Glasgow, Scotland). After curing, the section
was lapped to a thickness of approximately 120 μm, ultra-
sonicated, and again finished using a 1 μm polishing suspension.
The section was once more ultrasonicated, then dehydrated in an
alcohol series. Finally, the section was cleared in xylene and a
cover slip was applied using DPX Mountant (Sigma-Aldrich,
Carlsbad, CA, USA).
The diameters of five root canals (Fig. 4a, b) were digitally
analyzed by measuring the buccolingual and mesiodistal axes
(Fig. 4c) using the software ImageJ [76]. Each root canal was
measured three times, the values were averaged, and the mean
absolute error was calculated (Table 1). While the results indicate a
slight difference between the measurements of the μCT-based
virtual and the grinding section, the level of precision was suffi-
cient to suggest an application for μCT-based evaluations of root
canal diameters in macro-anatomical studies. However, results of
significantly higher precision can be obtained using the half
maximum height (HMH) method [77]. The HMH can be calculated
as the mean of two gray-scale levels on either side of an interface.
Kono and colleagues [78] adopted this approach to determine the
106 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111

exact position of a boundary between enamel and dentine. Using
this method, the diameter of a given root canal could be deter-
mined with the highest possible accuracy.
Table 1
Comparison of root canal diameters (x ¼mesiodistal, y¼ buccolingual) measured in
a grinding (histology) as well as a virtual (μCT) section of a maxillary left first molar.
The mean absolute error amounts to 12 μm. See Fig. 4 for an illustration of the
location of the sections and of each root canal.
Root canal Orientation Histology [μm] μCT [μm]
1 x 370 340
1 y 200 290
2 x 160 130
2 y 110 140
3 x 180 190
3 y 180 200
4 x 120 130
4 y 110 130
5 x 130 120
5 y 120 130
4.2. High-resolution micro-computed tomography in endodontics
Properties such as non-invasiveness, a relatively short scan time,
and cost-efficiency have rendered μCT an important tool for various
scientific disciplines. Because of the growing demand for advanced
μCT scanners, technical innovations have led to a constant
improvement of X-ray sources and detectors, resulting in high-
resolution desktop scanners that are now able to detect structural
details down to the nanometer scale [42,79]. These properties—here
illustrated by the difference between a μCT scan taken at 46 μm and
at 3 μm isotropic voxel resolution of the same tooth at the same
location (Fig. 5a)—can certainly also be employed for endodontic
studies. The single-digit micron resolution scan was made using the
latest generation of desktop μCT scanners (SkyScan 1272, Bruker
microCT, Kontich, Belgium).
4.3. Soft tissue imaging using micro-computed tomography
In addition to scans performed near or within the nanometer
scale, soft tissue imaging using μCT systems is rapidly gaining in
importance [80]. The approach using contrast-enhanced tissues
has recently also been applied to dental studies (Fig. 5b). In their
study of the microscopic detail of initiating teeth within the
embryonic jaw of a mouse, Raj and colleagues [81] used a silver-
based contrast agent to make the earliest stages of odontogenesis
visible in histological detail and in 3D. Due to the use of a SRμCT
system, the sample size in this particular study was relatively
small, but soft tissue staining can also be successfully employed
using samples in the centimeter scale [82] (Fig. 5c). This and the
following images (Fig. 5d and e) show the pharyngeal teeth of a
fresh water fish naturally surrounded by soft parts. Prior to μCT
scanning at 17 μm isotropic voxel resolution, the entire organism
of about 6 cm in length was immersed for four weeks in an
ethanol solution with added phosphotungstic acid that would act
as a soft tissue stain [83]. It would be of great interest to further
explore the usefulness of this μCT-based approach for the 3D
visualization of the pulp cavity and all soft tissues surrounding the
human tooth, in particular because new protocols for the staining
of specific tissues are now increasingly becoming available [84,85].
4.4. Finite element modeling based on computed tomography scans
Apart from high-resolution scans and soft part staining tech-
niques, μCT as well as CBCT also offer the opportunity to conduct
finite element modeling (FEM) analyses based on the datasets
generated using these non-invasive imaging techniques. Such an
approach has been employed, for example, in orthodontic treat-
ment planning [86,87] and dental restorative procedures [88–90].
FEM studies can help to understand and simulate changing stress
patterns in dental tissues, optimize the stability of treatment tools,
and therefore help to minimize the risk for the patient.
5. Potential uses of digital tooth data in dental education
Difference [μm]
The use of virtual reality has become an increasingly important
 30 component of dental education [1]. For example, prior to the
90 treatment of patients by dental students, virtual reality tools can
 30
be used as an adjunct to other preclinical teaching methods to
30
10 train problem solving and communication skills [91–93]. Virtual
20 reality has also been shown to be of value in other aspects of
10 dental education [1,8,10]. Nonetheless, dental students first need
20 to attain a thorough understanding of a tooth's external and
 10
10
internal structure, as this knowledge forms the basis for grasping
the function and potential disease of the tooth [2]. The different
forms of digital tooth data outlined in the previous sections pro-
vide a new basis for the increased use of virtual training tools in
dental education.
5.1. Interactive three-dimensional models of human teeth
In addition to the conventional physical tooth models tradi-
tionally used in dental education, several applications based on
virtual tooth models have been proposed for dental training
courses [94–97]. In contrast to these commercial systems, Kato
and colleagues [98] recently reported that freely accessible 3D
models of teeth embedded into portable document format (PDF)
files would constitute a valuable tool for dental students as well. In
their study, four publication-embedded tooth models based on
μCT datasets were presented that interactively permit the com-
parison of a tooth with regular root canal morphology and three
teeth showing different types of C-shaped root canals [98, p. 1024].
This approach is further illustrated in the present contribution by
an interactive 3D model complete with 3D labeling (Fig. 6). The
model portrays several aspects of the external as well as the
internal anatomy of an extracted maxillary first molar. The crea-
tion of PDF-embedded 3D models has previously been described
in detail [99–103] and recent advances now permit the stream-
lined and standardized creation of such files using open source
software packages [104,105]. From the perspective of endodontic
morphometrics research, calibrated 3D PDF models also permit
the numeric analysis of tooth shape by allowing measurements
directly within the electronic document.
The 3D aspect of the tooth presented here reveals that the
internal structures are more complex than would be expected
solely from an inspection of the external surface (Fig. 6a). For
example, the palatal root canal is flattened buccolingually and a
lateral branch runs towards the buccal surface of the palatal root
(Fig. 6b). In contrast, the mesiobuccal root canal is flattened
mesiodistally and tapers out into seven branches in its apical area
(Fig. 6c). Furthermore, the distobuccal root canal is the thinnest of
the three main root canals and set at an angle against its root canal
orifice. Further inspection of the virtual tooth model in 3D
(Fig. 6d–f) also shows that an access cavity preparation would be
the most challenging when using the structurally variable dis-
tobuccal root canal. Apart from the ability to freely manipulate the
embedded 3D model in Fig. 6 in the PDF version of this article, the
reader can also activate a series of pre-set views either by directly
accessing a view in the dropdown menu of the main viewer
window or by opening the “model tree” icon and switching from
one view to the next using the green arrows.
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111 107

Fig. 5. Advanced applications of μCT in dental research. (a) Comparison of low- vs. high-resolution μCT scans of a maxillary left first molar. In comparison to the lower
isotropic voxel resolution (left, 46 μm), the higher resolution (3 μm, right) provides additional information on the internal as well external hard parts of the tooth. The inset
shows a volume rendering of the entire, intact tooth and the approximate level of section (dashed black line). (b) SRμCT in combination with silver-based staining of the
mouth region of a mouse embryo reveals early odontogenesis. Modified from [81]. (c–e) Soft tissue staining in combination with μCT performed on the pharyngeal region of
a fresh water fish, the ide (Leuciscus idus Linnaeus, 1758). A virtual section through the dataset with 17 μm isotropic voxel resolution (c) reveals hard and soft tissues—the
arrow indicates a single pharyngeal tooth. A volume rendering of the dataset (d) shows a combination of soft parts (pharyngeal epithelium) and hard parts (mineralized
pharyngeal teeth), while threshold-based virtual removal of soft parts (e) results in the display of only the hard parts.

5.2. Dentistry students and interactive three-dimensional models
The numerous opportunities offered by 3D PDF documents have
a number of foreseeable implications for dental education. Although
a recent study found that 75% of students preferred using hard-
copies instead of electronic textbooks for learning [10], certain
morphological and anatomical skills can be more easily conveyed
using interactive 3D models. For example, 3D PDF documents made
available in parallel to a lecture or practical course provide students
with the opportunity to explore the models at their own pace in
parallel to teaching. In a preliminary experiment aimed at deter-
mining the impact of this approach, a small group of advanced (4th
grade) dental students at Aichi Gakuin University answered a
questionnaire (n¼6) following prolonged exposure to an interactive
3D PDF file in class. All students expressed the opinion that inter-
active educational materials were useful tools for studying tooth
anatomy. However, a few students remarked that, for them, con-
ventional 2D schematic illustrations like those found in textbooks
constitute an important source of information with which to grasp
complex anatomical structures. With regards to the specific
contents of the 3D PDF file, the students noted that the complex
structure of the lateral branches and apical ramifications of the pulp
cavity had particularly impressed them. These preliminary results
indicate that interactive 3D models such as the one shown in Fig. 6
must be seen as a valuable teaching supplement, but cannot yet be
used to replace the established forms of teaching materials in dental
education.
5.3. Additive manufacturing of three-dimensional human tooth
models
It could be argued that interactive 3D models that can be
operated on a personal computer do not fully convey a tooth's
morphology. As a remedy, 3D virtual models can now also be
made accessible to dental students as custom-made and scaled
physical objects through additive manufacturing (AM), thus pro-
viding students with a genuinely 3D interpretive experience
[106,107]. AM is a process by which different types of material can
be added layer-by-layer to produce a 3D object [108] and is
increasingly being used in the life sciences [109–111].
108 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111

Fig. 6. An example of a 3D PDF model suitable for dental education purposes. This figure contains an interactive model of a maxillary left first molar. Modeling was
performed based on a μCT dataset with 46 μm isotropic voxel resolution. (a) Mesial view with (b) increasing transparency and (c) removal of dentine and enamel to expose
the entire pulp cavity. (d) Apical view with (e) increasing transparency and (f) removal of dentine and enamel. In addition, (f) shows the root canals outlined in white
following virtual sectioning right below the apex. The embedded interactive 3D model can be activated by left-clicking anywhere on this figure in the PDF version of this
article (requires Acrobat Reader 9.0 or higher on all operating systems, right-click to deactivate the 3D mode).

The process is here illustrated showing separate 3D prints of
the enamel cap and dentine of a transparent human tooth model
(Fig. 7a). This model was printed using an ARM-10 rapid proto-
typing 3D printer (Roland DG Corp., Hamamatsu, Japan) that uses
a specific AM technique (optical shaping), where liquid resin is
cured by exposure to ultraviolet radiation. However, this particular
tooth model was printed to illustrate only the external features of
the tooth (Fig. 7b). Using the same technique, another tooth was
printed, but its hollow interior was filled with red ink (Fig. 7c) in
order to visualize the shape of the pulp cavity (Fig. 7d). Some of
the applications of AM in dental education include the possibility
to (1) scale the teeth for didactic purposes (Fig. 7d), (2) build a
collection of 3D tooth models showing atypical or only regionally
prevalent anatomies, (3) produce a large number of teeth for
destructive analysis, (4) present the teeth in the form of individual
substructures that need to be assembled correctly by the students,
and (5) build an extensive collection of 3D models of healthy and
diseased teeth using raw data made available online by research-
ers and dentists from all over the world.
5.4. Online deposition of three-dimensional tooth data
As illustrated above, modern non-invasive imaging techniques
such as μCT can be used to generate anatomical tooth data rapidly
and on a large scale. Because these data are digital, they can be
made publicly accessible through the internet, thus circumventing
the problems of individual researchers regarding access to scan-
ning systems [112]. A large amount of mammalian, primate, and
human tooth data being available online would certainly con-
stitute a significant resource for students, faculty, and researchers.
These data would permit a better understanding of the variation in
tooth morphology and anatomy from the species to the population
level, which is why we regard a centralized online database of
tooth models as highly desirable for both research and teaching.
Other disciplines in the life sciences, in particular zoology and
paleontology, have begun building repositories primarily for non-
invasively—but also for invasively—gathered 3D datasets [113,114].
Table 2 presents a selection of such data repositories for the life
sciences. Although some of these repositories are restricted to the
presentation of derived image data such as videos or interactive
3D models, several of them permit deposition of 3D imaging
datasets amounting to hundreds of gigabytes or even dozens of
terabytes of raw data. Given the constant progress in data storage
and archiving technology, it is just a matter of time until even
larger datasets become available online.
The field of dental education could profit in several ways by the
application of techniques and approaches that are already estab-
lished in other scientific disciplines. For example, the interactive
exploration of tooth anatomy online, expanded morphometric and
volumetric analyses of internal tooth structures, and large-scale
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111 109

Fig. 7. Additive manufacturing of human tooth models for dental education purposes. (a) 3D printer in the process of building the enamel cap and dentine of a transparent
human tooth model. (b) Close-up view of the final model prior to removal of the supporting struts—these structures are required during printing and need to be manually
removed afterwards. The tooth model is 4 cm high, while the original tooth was about half this size. (c) A water-based red ink is injected into the hollow root canal structures
of a semi-transparent tooth printed in 3D. (d) The final tooth model shows root canal morphology due to clearing using methyl methacrylate. The enamel caps were omitted
in order to show the entire shape of the pulp cavity. The inset shows a volume rendering of the original tooth scanned using μCT and illustrates the size difference between
the original object (2 cm high) and the 3D printout (7 cm high).

Table 2 CT scanners. Here, we have reported on several possibilities for the

A list of selected data repositories that host 3D image stacks as well as raw or application of such techniques in endodontic research and teach-
derived data based on non-invasive scans of biological specimens.
ing. Due to their digital nature, the large amount of tooth data
Repository Weblink likely to be made accessible online in the near future to
researchers, practitioners, students, as well as faculty will provide
Aves 3D http://aves3d.org/
a significant stimulus for the exploration of tooth anatomy. Fur-
Digital Fish Library (DFL) http://www.digitalfishlibrary.org/
Digital Morphology (Digimorph) http://digimorph.org/ thermore, the data derived from non-invasive imaging techniques
Dryad Digital Repository (Dryad) http://datadryad.org/ can be integrated into dental education and will help students to
Giga Data Base (GigaDB) http://gigadb.org/
acquire an improved understanding of the complex anatomy of the
Morphological Description https://www.morphdbase.de/
Data Base (Morph  D  Base) human tooth.
MorphoBank http://www.morphobank.org/
MorphoSource http://morphosource.org/
Phenome10k http://phenome10k.org/

Ethical approval

All experimental procedures conducted by the authors were

correlations of external and internal tooth morphology using 3D approved by the Ethics Committee of Aichi Gakuin University
virtual models are all methods that dental education could sig- (approval no. 67) and the Ethics Committee of the Rheinische
nificantly benefit from. Friedrich-Wilhelms-Universität Bonn.

6. Conclusions
Conflict of interest
The rapid increase of non-invasive and 3D imaging techniques
used for the study of internal tooth structures in recent years can The authors declare that they have no potential conflicts of
largely be attributed to the improvement of the various varieties of interest.
110 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111
Acknowledgments
We are grateful to Cornelius Faber (Westfälische Wilhelms-
Universität, Münster), Bing Fan (Wuhan University, Wuhan),
Hendrik Herzog (Rheinische Friedrich-Wilhelms-Universität,
Bonn), and Claudia Koch (Zoologisches Forschungsmuseum Alex-
ander König, Bonn) for providing access to MRI and μCT scanners
as well as datasets. We thank Masami Hattori and Takashi Harada
(Aichi Gakuin University, Nagoya) for their help regarding AM. We
are grateful to Andreas Ziegler (Ziegler Biosolutions, Waldshut-
Tiengen) and two anonymous reviewers for comments that helped
to improve the text. This work was funded in part by Aichi Gakuin
University.
References
[1] Eaton KA, Reynolds PA, Grayden SK, Wilson NHF. A vision of dental education
in the third millennium. Br Dent J 2008;205:261–71.
[2] Kato A, Higuchi N, Nakata K, Ohno N. Educational tools utilizing three-
dimensional portable document format aimed at comprehensive under-
standing of basic science and clinical dentistry. Aichi Gakuin J Dent Sci
2014;27:17–22.
[3] Patel B. Anatomy and root canal morphology. In: Patel B, editor. Endodontic
Diagnosis, Pathology, and Treatment Planning: Mastering Clinical Practice.
Springer International Publishing; 2015. p. 179–212.
[4] Preiswerk G. Die Pulpa-Amputation, eine klinische, pathohistologische und
bakteriologische Studie. Öst-Ung Vschr Zahnheilk 1901;17:145–220.
[5] Hess W. Zur Anatomie der Wurzelkanäle des menschlichen Gebisses mit
Berücksichtigung der feineren Verzweigungen am Foramen apicale. [Habi-
litation thesis]. Universität Zürich; 1917, 57 pages.
[6] Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investi-
gation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101–10.
[7] Vertucci F, Seelig A, Gillis R. Root canal morphology of the human maxillary
second premolar. Oral Surg Oral Med Oral Pathol 1974;38:456–64.
[8] Feeney L, Reynolds PA, Eaton KA, Harper J. A description of the new tech-
nologies used in transforming dental education. Br Dent J 2008;204:19–28.
[9] Battulga B, Konishi T, Tamura Y, Moriguchi H. The effectiveness of an inter-
active 3-dimensional computer graphics model for medical education.
Interact J Med Res 2012;1:2.
[10] Schleyer TK, Thyvalikakath TP, Spallek H, Dziabiak MP, Johnson LA. From
information technology to informatics: the information revolution in dental
education. J Dent Educ 2012;76:142–53.
[11] Fischer G. Über die feinere Anatomie der Wurzelkanäle menschlicher Zähne.
Dtsch Mschr Zahnheilk 1907;25:544–52.
[12] Okumura T. About the root canal issue. Shikagakuho 1911;16:1–35 (in
Japanese).
[13] Adloff P. Das Durchsichtigmachen von Zähnen und unsere Wurzelfüllungs-
methoden. Dtsch Mschr Zahnheilk 1913;6:445–7.
[14] Moral H. Ueber Pulpenausguesse. Dtsch Mschr Zahnheilk 1914;32:617–24.
[15] Moral H. Ueber das Vorkommen eines vierten Kanals in oberen Molaren. Öst-
Ung Vschr Zahnheilk 1915;33:313–25.
[16] Hess W. The anatomy of the root-canals of the teeth of the permanent dentition.
In: Hess W, editor. The Anatomy of the Root-Canals of the Teeth of the Per-
manent Dentition. London: John Bale Sons & Danielsson, Ltd.; 1925. p. 1–159.
[17] Mueller AH. Anatomy of the root canals of the incisors, cuspids and bicuspids
of the permanent teeth. J Am Dent Assoc 1933;20:1361–86.
[18] Barker BCW, Lockett BC, Parsons KC. The demonstration of root canal anat-
omy. Aust Dent J 1969;14:37–41.
[19] Pineda F. Roentgenographic investigation of the mesiobuccal root of the
maxillary first molar. Oral Surg Oral Med Oral Pathol 1973;36:253–60.
[20] Hession RW. Endodontic morphology. II. A radiographic analysis. Oral Surg
Oral Med Oral Pathol 1977;44:610–20.
[21] Benjamin K, Dowson J. Incidence of two root canals in human mandibular
incisor teeth. Oral Surg Oral Med Oral Pathol 1974;38:122–6.
[22] Hirano Y, Nagasuna T, Utsumi N. An embedding method using polyester
resin of the transparent specimen of teeth showing the pulp cavity per-
meated with India ink and a method applying silicone oil to the transparent
specimen. J Osaka Odont Soc 1958;21:913–23 (in Japanese).
[23] Carns EJ, Skidmore AE. Configurations and deviations of root canals of
maxillary first premolars. Oral Surg Oral Med Oral Pathol 1973;36:880–6.
[24] Hasselgren G, Tronstad L. The use of transparent teeth in the teaching of
preclicnical endodontics. J Endod 1975;1:278–80.
[25] Yang ZP, Yang SF, Lee G. The root and root canal anatomy of maxillary molars
in a Chinese population. Dent Traumatol 1988;4:215–8.
[26] Yang ZP, Yang SF, Lin YC, Shay JC, Chi CY. C-shaped root canals in mandibular
second molars in a Chinese population. Dent Traumatol 1988;4:160–3.
[27] Manning SA. Root canal anatomy of mandibular second molars. Part II. C-
shaped canals. Int Endod J 1990;23:40–5.
[28] Sidow SJ, West LA, Liewehr FR, Loushine RJ. Root canal morphology of
human maxillary and mandibular third molars. J Endod 2000;26:675–8.
[29] Gulabivala K, Aung TH, Alavi A, Ng YL. Root and canal morphology of Bur-
mese mandibular molars. Int Endod J 2001;34:359–70.
[30] Peiris R, Takahashi M, Sasaki K, Kanazawa E. Root and canal morphology of
permanent mandibular molars in a Sri Lankan population. Odontology
2007;95:16–23.
[31] Peiris R. Root and canal morphology of human permanent teeth in a Sri
Lankan and Japanese population. Anthropol Sci 2008;116:123–33.
[32] Velmurugan N, Sandhya R. Root canal morphology of mandibular first pre-
molars in an Indian population: a laboratory study. Int Endod J 2008;42:54–8.
[33] Al-Qudah AA, Awawdeh LA. Root and canal morphology of mandibular first and
second molar teeth in a Jordanian population. Int Endod J 2009;42:775–84.
[34] Neelakantan P, Subbarao C, Subbarao CV, Ravindranath M. Root and canal
morphology of mandibular second molars in an Indian population. J Endod
2010;36:1319–22.
[35] Berutti E. Computerized analysis of the instrumentation of the root canal
system. J Endod 1993;19:236–8.
[36] Blašković‐Šubat V, Smojver I, Maričić B, Šutalo J. A computerized method for
the evaluation of root canal morphology. Int Endod J 1995;28:290–6.
[37] Pohmann R. Physical basics of NMR. Method Mol Biol 2011;771:3–21.
[38] Tymofiyeva O, Rottner K, Jakob PM, Richter EJ, Proff P. Three-dimensional
localization of impacted teeth using magnetic resonance imaging. Clin Oral
Invest 2009;14:169–76.
[39] Ziegler A, Kunth M, Mueller S, Bock C, Pohmann R, Schröder L, Faber C,
Giribet G. Application of magnetic resonance imaging in zoology. Zoomor-
phol 2011;130:227–54.
[40] Tymofiyeva O, Boldt J, Rottner K, Schmid F, Richter EJ, Jakob PM. High-
resolution 3D magnetic resonance imaging and quantification of carious
lesions and dental pulp in vivo. Magn Reson Mater Phys Biol Med
2009;22:365–74.
[41] Gaudino C, Cosgarea R, Heiland S, Csernus R, Zobel BB, Pham M, Kim T,
Bendszus M, Rohde S. MR-Imaging of teeth and periodontal apparatus: an
experimental study comparing high-resolution MRI with MDCT and CBCT.
Eur Rad 2011;21:2575–83.
[42] Stauber M, Müller R. Micro-computed tomography: a method for the non-
destructive evaluation of the three-dimensional structure of biological spe-
cimens. Method Mol Biol 2008;455:273–92.
[43] Hounsfield GN. Computerized transverse axial scanning (tomography): Part
I. Description of system. Br J Rad 1973;46:1016–22.
[44] Gopikrishna V, Bhargavi N, Kandaswamy D. Endodontic management of a
maxillary first molar with a single root and a single canal diagnosed with the
aid of spiral CT; a case report. J Endod 2006;32:687–91.
[45] Ma L, Chen J, Wang H. Root canal treatment in an unusual maxillary first
molar diagnosed with the aid of spiral computerized tomography and
in vitro sectioning: a case report. Oral Surg Oral Med Oral Pathol Oral Rad
Endod 2009;107:68–73.
[46] Sponchiado Jr EC, Ismail HAAQ, Braga MRL, de Carvalho FK, Simoes CACG.
Maxillary central incisor with two root canals: a case report. J Endod
2006;32:1002–4.
[47] Ballal S, Sachdeva GS, Kandaswamy D. Endodontic management of a fused
mandibular second molar and paramolar with the aid of spiral computed
tomography: a case report. J Endod 2007;33:1247–51.
[48] Nakata K, Naitoh M, Izumi M, Inamoto K, Ariji E, Nakamura H. Effectiveness
of dental computed tomography in diagnostic imaging of periradicular lesion
of each root of a multirooted tooth: a case report. J Endod 2006;32:583–7.
[49] Dawood A, Patel S, Brown J. Cone beam CT in dental practice. Br Dent J
2009;207:23–8.
[50] Leung SF. Cone beam computed tomography in endodontics. Hong Kong
Med Diary 2010;15:16–9.
[51] Kaneko T, Sakaue H, Okiji T, Suda H. Clinical management of dens invagi-
natus in a maxillary lateral incisor with the aid of cone-beam computed
tomography – a case report. Dent Traumatol 2011;27:478–83.
[52] Cheung GSP, Yang J, Fan B. Morphometric study of the apical anatomy of C‐
shaped root canal systems in mandibular second molars. Int Endod J
2007;40:239–46.
[53] Naitoh M, Kinoshita H, Gotoh K, Ariji E. Cone-beam computed tomography
images of phantoms with simulating trabecular bone structure fabricated
using micro-stereolithography. Okajimas Folia Anat Jpn 2012;89:27–33.
[54] Al-Rawi B, Hassan B, Vandenberge B, Jacobs R. Accuracy assessment of three‐
dimensional surface reconstructions of teeth from cone beam computed
tomography scans. J Oral Rehab 2010;37:352–8.
[55] Pauwels R, Beinsberger J, Stamatakis H, Tsiklakis K, Walker A, Bosmans H,
Bogaerts R, Jacobs R, Horner K. The SEDENTEXCT Project Consortium. Com-
parison of spatial and contrast resolution for cone-beam computed tomo-
graphy scanners. Oral Surg Oral Med Oral Pathol Oral Rad 2012;114:127–35.
[56] Maret D, Peters OA, Galibourg A, Dumoncel J, Esclassan R, Kahn JL, Sixou M,
Telmon N. Comparison of the accuracy of 3-dimensional cone-beam com-
puted tomography and micro-computed tomography reconstructions by
using different voxel sizes. J Endod 2014;40:1321–6.
[57] Byun C, Kim C, Cho S, Baek SH, Kim G, Kim SG, Kim SY. Endodontic treatment
of an anomalous anterior tooth with the aid of a 3-dimensional printed
physical tooth model. J Endod 2015;41:961–5.
[58] Rathi S, Patil J, Jaju PP. Detection of mesiobuccal canal in maxillary molars
and distolingual canal in mandibular molars by dental CT: a retrospective
study of 100 cases. Int J Dent 2010:291276.
 A. Kato et al. / Journal of Oral Biosciences 58 (2016) 100–111
[59] Zhang R, Wang H, Tian YY, Yu X, Hu T, Dummer PMH. Use of cone‐beam
computed tomography to evaluate root and canal morphology of mandibular
molars in Chinese individuals. Int Endod J 2011;44:990–9.
[60] Suzuki M, Tsujimoto Y, Kondo S. Morphological variations of the root canal
system in C-shaped roots of the mandibular second molar in a Japanese
population. Int J Oral-Med Sci 2015;13:81–8.
[61] Shiota T, Kuni Y, Kishi T, Ohnishi S, Yamada K, Edahiro M, Kamegawa M.
Development of microfocus X-ray CT system. Shimadzu Hyoron 2001;58:19–
26 (in Japanese).
[62] Tafforeau P, Boistel R, Boller E, Bravin A, Brunet M, Chaimanee Y, Cloetens P,
Feist M, Hoszowska J, Jaeger JJ, Kay RF, Lazzari V, Marivaux L, Nel A, Nemoz C,
Thibault X, Vignaud P, Zabler S. Applications of X-ray synchrotron micro-
tomography for non-destructive 3D studies of paleontological specimens.
Appl Phys A – Mater 2006;83:195–202.
[63] Tafforeau P, Smith TM. Nondestructive imaging of hominoid dental micro-
structure using phase contrast X-ray synchrotron microtomography. J Hum
Evol 2008;54:272–8.
[64] Tafforeau P, Zermeno JP, Smith TM. Tracking cellular-level enamel growth
and structure in 4D with synchrotron imaging. J Hum Evol 2012;62:424–8.
[65] Nielsen RB, Alyassin AM, Peters DD, Carnes DL, Lancaster J. Microcomputed
tomography: an advanced system for detailed endodontic research. J Endod
1995;21:561–8.
[66] Dowker SEP, Davis GR, Elliott JC. X-ray microtomography. Nondestructive
three-dimensional imaging for in vitro endodontic studies. Oral Surg Oral
Med Oral Path Oral Rad Endod 1997;83:510–6.
[67] Rhodes JS, Pitt Ford TR, Lynch JA, Liepins PJ, Curtis RV. Micro‐computed
tomography: a new tool for experimental endodontology. Int Endod J
1999;32:165–70.
[68] Peters OA, Laib A, Rüegsegger P, Barbakow F. Three-dimensional analysis of
root canal geometry by high-resolution computed tomography. J Dent Res
2000;79:1405–9.
[69] Mannocci F, Peru M, Sherriff M, Cook R, Pitt Ford TR. The isthmuses of the
mesial root of mandibular molars: a micro‐computed tomographic study. Int
Endod J 2005;38:558–63.
[70] Lee JK, Yoo YJ, Perinpanayagam H, Ha BH, Lim SM, Oh SR, Gu Y, Chang SW,
Zhu Q, Kum KY. Three‐dimensional modelling and concurrent measure-
ments of root anatomy in mandibular first molar mesial roots using micro‐
computed tomography. Int Endod J 2015;48:380–9.
[71] Ordinola-Zapata R, Bramante CM, Villas-Boas MH, Cavenago BC, Duarte MH,
Versiani MA. Morphologic micro–computed tomography analysis of man-
dibular premolars with three root canals. J Endod 2013;39:1130–5.
[72] Gao Y, Fan B, Cheung GSP, Gutmann JL, Fan M. C-shaped canal system in
mandibular second molars part IV: 3-D morphological analysis and trans-
verse measurement. J Endod 2006;32:1062–5.
[73] Tanaka M, Arai K, Kitajima K, Igarashi M, Kawasaki K. A preliminary inves-
tigation on the presence of accessory foramina in human mandibular molar
furcations with gutter shaped roots by micro-CT analysis. Jpn J Conserv Dent
2007;50:530–8 (in Japanese).
[74] Peters OA, Laib A, Göhring TN, Barbakow F. Changes in root canal geometry
after preparation assessed by high-resolution computed tomography. J
Endod 2001;27:1–6.
[75] Peters OA, Arias A, Paqué F. A micro-computed tomographic assessment of
root canal preparation with a novel instrument, TRUShape, in mesial roots of
mandibular molars. J Endod 2015;41:1545–50.
[76] Schneider CA, Rasband WS, Eliceiri KW. NIH Image to ImageJ: 25 years of
image analysis. Nat Methods 2012;9:671–5.
[77] Spoor CF, Zonneveld FW, Macho GA. Linear measurements of cortical bone
and dental enamel by computed tomography: applications and problems.
Am J Phys Anthropol 1993;91:469–84.
[78] Kono RT, Suwa G, Tanijiri T. Three-dimensional reconstruction and analysis
of serially scanned CT image data using CT-Rugle software. Gazolabo
2000;11:48–52 (in Japanese).
[79] Khoury BM, Bigelow EMR, Smith LM, Schlecht SH, Scheller EL, Andaris-Puri
N, Jepsen KJ. The use of nano-computed tomography to enhance muscu-
loskeletal research. Connect Tissue Res 2015;56:106–19.
[80] Gignac PM, Kley NJ, Clarke JA, Colbert MW, Morhardt AC, Cerio D, Cost IN,
Cox PG, Daza JD, Early CM, Echols MS, Henkelman RM, Herdina AN, Holliday
CM, Li Z, Mahlow K, Merchant S, Müller J, Orsbon CP, Paluh DJ, Thies ML, Tsai
HP, Witmer LM. Diffusible iodine-based contrast-enhanced computed
tomography (DiceCT): an emerging tool for rapid, high-resolution, 3-D
imaging of metazoan soft tissue. J Anat 2016;228:889–909.
[81] Raj MT, Prusinkiewicz M, Cooper DM, George B, Webb MA, Boughner JC.
Technique: imaging earliest tooth development in 3D using a silver‐based
tissue contrast agent. Anat Rec. 2014;297:222–33.
[82] Li Z, Clarke JA, Ketcham RA, Colbert MW, Yan F. An investigation of the
efficacy and mechanism of contrast-enhanced X-ray computed tomography
utilizing iodine for large specimens through experimental and simulation
approaches. BMC Physiol 2015;15:5.
[83] Metscher BD. MicroCT for comparative morphology: simple staining meth-
ods allow high-contrast 3D imaging of diverse non-mineralized animal tis-
sues. BMC Physiol 2009;9:11.
[84] Nierenberger M, Rémond Y, Ahzi S, Choquet P. Assessing the three-dimensional
collagen network in soft tissues using contrast agents and high resolution
micro-CT: application to porcine iliac veins. CR Biol 2015;338:425–33.
111
[85] Balint R, Lowe T, Shearer T. Optimal contrast agent staining of ligaments and
tendons for X-ray computed tomography. Plos One 2016;11:0153552.
[86] Cattaneo PM, Dalstra M, Melsen B. The finite element method: a tool to study
orthodontic tooth movement. J Dent Res 2005;84:428–33.
[87] Ammar HH, Ngan P, Crout RJ, Mucino VH, Mukdadi OM. Three-dimensional
modeling and finite element analysis in treatment planning for orthodontic
tooth movement. Am J Orthod Dent Orthop 2011;139:59–71.
[88] Verdonschot N, Fennis WMM, Kuijs RH, Stolk J, Kreulen CM, Creugers NHJ.
Generation of 3-D finite element models of restored human teeth using
micro-CT techniques. Int J Prosthod 2001;14:310–5.
[89] Barink M, van der Mark PCP, Fennis WMM, Kuijs RH, Kreulen CM, Ver-
donschot N. A three-dimensional finite element model of the polymerization
process in dental restorations. Biomater 2003;24:1427–35.
[90] Magne P. Efficient 3D finite element analysis of dental restorative procedures
using micro-CT data. Dent Mater 2007;23:539–48.
[91] Phillips J, Berge ZL. Second life for dental education. J Dent Educ
2009;73:1260–4.
[92] Dias DRC, Brega JRF, Guimarães MP, Modesto F, Gnecco BB, Lauris JRP. 3D
semantic models for dental education. Springer Berlin Heidelberg: ENTER-
prise Information Systems; 2011. p. 89–96.
[93] Vuchkova J, Maybury TS, Farah CS. Testing the educational potential of 3D
visualization software in oral radiographic interpretation. J Dent Educ
2011;75:1417–25.
[94] Steinberg AD, Bashook PG, Drummond J, Ashrafi S, Zefran M. Assessment of
faculty perception of content validity of Periosim©, a haptic-3D virtual
reality dental training simulator. J Dent Educ 2007;71:1574–82.
[95] Marras I, Nikolaidis N, Mikrogeorgis G, Lyroudia K, Pitas I. A virtual system
for cavity preparation in endodontics. J Dent Educ 2008;72:494–502.
[96] Yoshida Y, Yamaguchi S, Kawamoto Y, Noborio H, Murakami S, Sohmura T.
Development of a multi-layered virtual tooth model for the haptic dental
training system. Dent Mater J 2011;30:1–6.
[97] De Boer IR, Wesselink PR, Vervoorn JM. The creation of virtual teeth with and
without tooth pathology for a virtual learning environment in dental edu-
cation. Eur J Dentofac Educ 2013;17:191–7.
[98] Kato A, Ziegler A, Higuchi N, Nakata K, Nakamura H, Ohno N. Aetiology,
incidence and morphology of the C-shaped root canal system and its impact
on clinical endodontics. Int Endod J 2014;47:1012–33.
[99] Kumar P, Ziegler A, Ziegler J, Uchanska-Ziegler B, Ziegler A. Grasping mole-
cular structures through publication-integrated 3D models. Trends Biochem
Sci 2008;33:408–12.
[100] Kumar P, Ziegler A, Grahn A, Hee CS, Ziegler A. Leaving the structural ivory
tower, assisted by interactive 3D PDF. Trends Biochem Sci 2010;35:419–22.
[101] Ziegler A, Mietchen D, Faber C, von Hausen W, Schöbel C, Sellerer M, Ziegler
A. Effectively incorporating selected multimedia content into medical pub-
lications. BMC Med 2011;9:17.
[102] Danz JC, Katsaros C. Three-dimensional portable document format: a simple
way to present 3-dimensional data in an electronic publication. Am J Orthod
Dentofac Orthop 2011;140:274–6.
[103] Lautenschlager S. Palaeontology in the third dimension: a comprehensive
guide for the integration of three-dimensional content in publications.
Palaeon Z 2014;88:111–21.
[104] Newe A, Ganslandt T. Simplified generation of biomedical 3D surface model
data for embedding into 3D Portable Document Format (PDF) files for pub-
lication and education. Plos One 2013;8:79004.
[105] Newe A. Towards an easier creation of three-dimensional data for embedding
into scholarly 3D PDF (portable document format) files. Peer J 2015;3:794.
[106] Torres K, Staskiewicz G, Sniezynski M, Drop A, Maciejewski R. Application of
rapid prototyping techniques for modelling of anatomical structures in
medical training and education. Fol Morph 2011;70:1–4.
[107] McMenamin PG, Quayle MR, McHenry CR, Adams JW. The production of
anatomical teaching resources using three-dimensional (3D) printing tech-
nology. Anat Sci Educ 2014;7:479–86.
[108] Melchels FPW, Domingos MAN, Klein TJ, Malda J, Bartolo PJ, Hutmacher DW.
Additive manufacturing of tissues and organs. Prog Polym Sci 2012;37:1079–
104.
[109] Kelley DJ, Farhoud M, Meyerand ME, Nelson DL, Ramirez LF, Dempsey RJ,
Wolf AJ, Alexander AL, Davidson RJ. Creating physical 3D stereolithograph
models of brain and skull. Plos One 2007;2:1119.
[110] Tesařová M, Zikmund T, Kaucká M, Adameyko I, Jaroš J, Paloušek D, Škar-
oupka D, Kaiser J. Use of micro computed-tomography and 3D printing for
reverse engineering of mouse embryo nasal capsule. J Instrum 2016;11:
C03006.
[111] Lauridsen H, Hansen K, Nørgård MØ, Wang T, Pedersen M. From tissue to
silicon to plastic: three-dimensional printing in comparative anatomy and
physiology. R Soc Open Sci 2016;3:150643.
[112] Kato A, Ohno N. Construction of three-dimensional tooth model by micro-
computed tomography and application for data sharing. Clin Oral Invest
2009;13:43–6.
[113] Ziegler A, Ogurreck M, Steinke T, Beckmann F, Prohaska S, Ziegler A.
Opportunities and challenges for digital morphology. Biol Direct 2010;5:45.
[114] Rowe T, Frank LR. The disappearing third dimension. Science 2011;331:712–3.