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New Technologies and 3D Imaging — “The Virtual Microscope”

Dental technologies are constantly being developed, and each clinician must decide which innovations best fit their individual practice needs. I pride myself being on the “leading edge” of technology but not the “bleeding edge” of technology. This entails that I implement products that have been researched with scientific evidence and are proven as clinically viable. As an endodontic specialist, patients have higher expectations when visiting my practice, so I feel the need to go above and beyond to provide quality treatment. Three technologies in particular — magnification/illumination, 2D digital imaging, and 3D CBCT imaging have improved my diagnostic, patient-education and clinical skills to help to keep our practice ahead of the curve. This will continue to build our reputation as local experts to assist our referring dentist in a team approach in providing the highest quality of care to our community.

 A good microscope with powerful illumination is imperative technology for endodontists. I personally invested in a microscope (Global) in 2004.  It has been repeatedly shown in the research that the dental operating microscope allows practitioners to locate anatomy at a far greater rate than the unaided eye. This in turn allows one to be minimally invasive during the root canal procedures, which eventually benefits the referring dentist to have greater amount of tooth structure to restore and better serving the patient overall. When microscopy was introduced in the 1990s, clinicians were resistant to using it and challenged its expense and increase in better outcomes. Now, microscopy has evolved to be one of our standards of care and very few specialists could work without.

The same concept is true with other types of technology. Many dental practices have evolved from using traditional film, to 2D digital radiography to 3D CBCT. Each time, the view of the anatomy becomes appreciably more detailed.

Because endodontics necessitates capturing a fair amount of radiographs, endodontists appreciate 2D digital imaging because it emits a lower amount of radiation than traditional film radiography.. Studies have shown that capturing one view of a tooth garners only a limited percentage of information, but both a straight-on view and an angled view results in a greater amount of details. Also, in a digital format, quick access to the data also results in more efficient use of time. During endodontic treatment, I may need a check radiograph to see if I am in the proper length for a root canal, or if I am in the proper orientation for access, and my digital system helps me to quickly capture that type of image. For these “check” radiographs, sensor holders in the shape of paddles that allow the rubber dam to stay on while taking this image and not breaking the sterilization protocol.

I like the features in Sidexis  and the ability to incorporate the SiCat Endo suite into my platform , I can switch between 2D and 3D images, and I don’t have to open up different software. This type of workflow ease is essential in streamlining the patients experience in and out of the chair.

3D technology allows for very thorough treatment planning. While I do not take a 3D scan on every patient, 3D images will be captured when we feel the benefit outweighs the risk to the patient. Some examples of this would be for as a failing root canal, a presurgical consultation, to determine an odontogentic or non-odontogenic lesion, or if the source of the patient’s chief complaint is not obvious on the 2D radiograph. Some other uses for CBCT are when I sense complicated anatomy, resorption, perforations, or instrument failures.

The 3D imaging software also allows me to take measurements which I then use in conjunction with my microscope to located difficult anatomy in a conservative manner. Also, I can be more modest when using a CBCT during treatment planning. The technology helps me confirm when not to treat certain “hopeless” teeth. Before implementing 3D imaging, I would have had to open up the tooth or have done an irreversible procedure only to discover that tooth could not be saved.

It is interesting to note that “when looking at preoperative image with CBCT … 62% of operators changed their treatment plan” because they receive more information.1 Treatment changes when one has the full knowledge to create a more thorough treatment plan.

Patients also benefit from seeing their images. I have a monitor on the foot rest of the patient’s chair that I use to show both 2D and 3D images. When they see their images in conjunction with my explanation, patients understand the problem and why they need a certain procedure. Case acceptance goes up tremendously when a patient is actively involved in their own health care.

Here is some advice before adding 3D technology to your office. Learning to use a CBCT is not difficult, but check to make sure that proper training is incorporated into the cost of the machine. Look for a company that has a good track record when it comes to service and standing behind the product they sell you. There is a learning curve so stick with it and get help from mentors when needed. Also, choose a brand within ALARA (as low as reasonably achievable) for radiation standards. If you are uncomfortable with reading CBCT images or suspect an anomaly, send the scan to an oral radiologist.

Endodontists are notorious for being early adopters of technology. I can’t believe that it has been 12 years since I began using 2D digital radiography. As with my other technologies, my investments continue to pay back over the years in better diagnostics and more efficient treatment methods. When patients see these high quality imaging methods and realize that their endodontist is investing in better patient care, the reputation boost will supersede your monetary return.


1 Ee J, Fayad MI, Johnson BR.  Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. J Endod. 2014;40(7):910-916.