recent advances in imagingin conservative dentistry and endodontics .pptx

recent advances in imaging techniques in dentistry ,especially endodontics and also in caries research ,the recent advances are covered

1. ADVANCES IN DIGITAL IMAGING DR. K.SADASIVA Prof & HOD, Department of conservative dentistry &endodontics CHETTINAD DENTAL COLLEGE AND RESEARCH INSTITUTE

2. EXAM QUESTIONS- Recently asked questions ROLE OF RADIOGRAPHS IN ENDODONTIC DIAGNOSIS (2013) • DISCUSS RECENT ADVANCES IN IMAGING TECHNIQUES (RGUHS 2007) • DISCUSS LATEST DIAGNOSTIC METHODS IN CONSERVATIVE DENTISTRY AND ENDODONTICS (RGUHS 2006) • CRITICAL APPRAISAL OF DIGITAL IMAGING SYSTEMS IN RESTORATIVE DENTISTRY AND ENDODONTICS – TNMGR 2014 • NEWER DIAGNOSTIC AIDS IN ENDODONTICS ( TNMGR OCT 2016) • RECENT ADVANCES IN IMAGING TECHNOLOGY (TNMGR JULY 2023) • GUIDED ENDODONTICS (TNMGR JULY 2023)

3. DIAGNOSTIC AIDS IN ENDODONTICS (NTRUHS 2022) • CONE BEAM COMPUTED TOMOGRAPHY IN ENDODONTICS ( OCT 2017) • ROLE OF CBCT IN ENDODONTICS (2008) • ADVANCEMENTS IN DEVICES TO MANAGE THE COMPLEXITIES OF RC SYSTEM (TNMGR 2018) • DIAGNOSING VERTICAL FRACTURE (2016) • RECENT ADVANCES IN CARIES DETECTION ( 2015) • RADIOLOGY IN ENDODONTICS (2009) • DIGITAL IMAGING SYSTEMS (2011) • DIGITAL TECHNOLOGY IN ENDODONTIC PRACTICE (2012)

4. INTRODUCTION Radiographic examination is an indispensable adjunct to clinical examinations in endodontics. In most endodontic cases, the periapical radiograph is the image of choice as it provides a high definition image at a low dose , provides useful information for the presence and location of periradicular lesions, root canal anatomy and the proximity of adjacent anatomical structures . But conventional radiographs has got lot of drawbacks in reproducing the three-dimensional analysis which is required in certain endodontic clinical scenarios. Hence, the need of recent advances in endodontic imaging arised and useful tool in clinical scenarios

5. HISTORY 1895 – Discovery of cathode rays by Roentgen 1895 – Dr. Otto Walkoff took the 1 st dental X ray (of his own teeth) 1899 – Dr. Edmund Kells used Radiographs to determine the root length during RCT 1900 – Dr. Weston Price advocated the use of radiographs to check the adequacy of root canal fillings 1982 for angiographic applications- First CBCT prototype scanner 1990S- CBCT Maxillofacial skeleton

6. Complex oral anatomy may obscure the anatomic features in radiographs by Superimposition First observed by Brynolf (1967, 1970) Pre-treatment, post-treatment and follow-up radiographs should be standardized with respect to their radiation geometry, density and contrast LIMITATIONS OF CONVENTIONAL RADIOGRAPHS Endodontic imaging-recent advances: a review, Dr. Swati Bhosale Dr. M Rameshkumar, INTERNATIONAL DENTAL JOURNAL OF STUDENT’S RESEARCH, April 2016

7. IMAGING TECHINIQUE Conventional Film Radiography Digital Radiography(RVG,CCD, CMOS, PSP) Digital Subtraction Radiography Chan EK, Wah YY, Lam WY, Chu CH, Yu OY. Use of Digital Diagnostic Aids for Initial Caries Detection: A Review. Dentistry journal. 2023 Sep 28;11(10):232.

8. RADIOVISIOGRAPHY Digital radiography refers to a method of capturing a radiographic image using a solid-state technology sensor, breaking it into electronic pieces, and presenting and storing the image using a computer. Radio- visio - graphy Trophy in France in 1987 Dose reduction up to 80% Shah N, Bansal N, Logani A. Recent advances in imaging technologies in dentistry. World J Radiol . 2014 Oct 28;6(10):794-807   VATECH, KODAK, WOODPECKER

9. CCD & CMOS (DIRECT DIGITAL IMAGING) PSP (INDIRECT DIGITAL IMAGING) High signal-to-noise ratio Instantaneous display of the captured image Cost and difficulty in sensor placement. minimal modification in technique needed phosphor plate has the same dimensions as traditional film Processing time is more and receptor life span is less Jayachandran S. Digital Imaging in Dentistry: A Review. Contemp Clin Dent. 2017 Apr-Jun;8(2):193-194.

10. FEATURE FILM CCD/CMOS PSP RADIATION DOSE Higher lower Lower IMAGE VIEWING Delayed Real time on computer Delayed ,computer monitor RESOLUTION 16-20 Lp /mm 8-10Lp/mm 6-8 Lp /mm CONSTRUCTION Thin,flexible Thick,rigid Thick, rigid LIFE SPAN One use Reusable >10,000 Reusable unknown GENERATION OF VISIBLE IMAGE Chemical processing Computer Computer , scanning laser ACTIVE AREA Entire surface of film Smaller than size of sensor Entire surface IMAGE ENHANCEMENT Unchanged Mutiple operations. magnification Density, contrast STORAGE Pt record Variety of archiving methods,server , zip,cd ,

11. Digital Subtraction Radiography B. G. Zeides des Plantes introduced subtraction methods in1920s. In dentistry, it was introduced in the year 1980. It uses comparison of standardized radiographs achieved at sequential visits of examination. Since digital subtraction radiography eliminates the complicated anatomic backdrop that the small changes occur against, digital subtraction radiography is effective.

12. Digital Bitewing Radiographs Digital bitewing radiography uses photographic film or digital detectors to capture images when X-rays interact with the emulsion on the film This technology provides a qualitative diagnosis by enabling the observation of lesion extension or density changes in enamel or dentine over time and allows for the long-term monitoring of carious lesions DISADVANTAGES: Increased radiation risk It cannot distinguish between active and arrested carious lesions and sometimes between cavitated and non- cavitated surfaces, as the radiographic lesion depth does not always reflect the actual caries lesion It can detect lesions with a depth of at least 500 µm in the enamel. The inability to detect initial carious lesions limits its clinical value Planmeca ProXTM ( Planmeca , Helsinki, Finla

13. CONE BEAM -Computed Tomography CBCT can be employed to detect caries in all sites of a tooth because it provides three-dimensional images(Frontal, Sagital and Axial ) CBCT has a increased sensitivity and specifity .

14. It is based on the changes in the scattering and absorption phenomenon of light photons and increase in between sound and enamel caries . Light propagates from the fiber illuminator across tooth tissue to non-illuminated surfaces. Carious areas appear dark. It has been show that FOTI diagnosis by naked eye can be subject to great inter- and intra-examiner variation FOTI – Fiber optic transillumination

15. DIFOTI- Digital Imaging Fiber Optic Transillumination DIFOTI is a method which employs digital image processing for quantitative diagnosis and prognosis in dentistry. It is based on light propagation just below the tooth surface and can be used to determine lesion depth . It uses fiber-optic transillumination of safe visible light to image the tooth. In this system, light delivered by a fiber-optic is collected on the other side of the tooth by a mirror system and recorded with a CCD imaging camera instantaneously.

16. DIAGNOcam ( KaVo Dental GmbH, Birebach / Ri ẞ, Germany ) i-Tero (Align Technology, California, USA)

17. Fluorescence Light-Induced Fluorescence Fluorescence is a type of luminescence, or the emission of light of longer wavelengths from a substance after absorbing light or other electromagnetic radiation at low wavelengths Light with various wavelengths has been used to induce fluorescence in caries lesion, including ultraviolet light (100–400 nm), the green–yellow end of the visible light (370 nm), the blue–violet end of the visible light (400–450 nm), and near-infrared light (750–10,000 nm) When a carious lesion absorbs light of short wavelengths, it re-emits light at a longer wavelength, creating a colour change during the process. (A) QLF system. (B) Fluorescence image of an enamel caries lesion on the buccal surface. (C) Fluorescence image of an occlusal caries lesion. (D) Fluorescence image of a secondary caries lesion around a composite restoration

18. ADVANTAGES: Applied to multiple surfaces of the carious tooth , including the occlusal surface, the buccal/lingual surface, or the proximal surface with reasonable interproximal space. Quantification of the mineral loss in the caries lesion by capturing the average loss of fluorescence in carious tooth Lower radiation dose. Reduced patient discomfort. Real-time image viewing, and storage.

19. Laser-Induced Fluorescence Laser-induced fluorescence employs a red-light laser at a wavelength of greater than 655 nm to stimulate fluorescence in carious tissues. The laser can induce fluorescence derived from protoporphyrin, a photosensitive pigment resulting from bacterial metabolic activities in carious lesions, to facilitate caries detection It can estimate the depth of the carious lesion and display a value from 0 to 99, in which lower scores indicate healthy tissues and higher scores reflect the need for restorative treatment Healthy dental tissues produce little or no fluorescence, the emitted fluorescence intensity correlates with the caries severity.

20. Spectra (Air Techniques, New York, USA) 3Shape TRIOS 4 (3Shape, Copenhagen , Denmark) DIAGNOdent 2190 or DIAGNOdent pen

21. Fluorescence camera ( VistaProof ) Based on six blue GaN -LEDs emitting a 405-nm light . With this camera it is possible to digitize the video signal from the dental surface during fluorescence emission using a CCD sensor (charge coupled device) Possible to see different areas of the dental surface that fluoresce in green (sound dental tissue) and in red (carious dental tissue) The higher is the bacterial colonization, the higher is the red fluorescent signal. The software highlights the lesions and classifies them in a scale from 0 to 5, giving a treatment orientation in the first evaluation Diniz MB, Rodrigues JA, Lussi A. Traditional and novel caries detection methods. Contemporary approach to dental caries. 2012 Mar 14;6:105-28.

22. LED technology (Midwest Caries I.D.) It is a handheld device emits a soft light emitting diode (LED) between 635 nm and 880 nm and analyzes the reflectance and refraction of the emitted light from the tooth surface, which is captured by fiber optics and is converted to electrical signals for analysis. The demineralization leads to a change in the LED from green to red with a simultaneous audible signal , which is directly related to the severity of caries lesions. The faster the signal, the deeper the lesion Midwest Caries I.D. device

23. Electric-Based Diagnostic Aids It was first proposed by Emile Magitot in 1878. Electric-based caries detection devices work based on the phenomenon that hydroxyapatite, which is the main component of dental enamel, has high electrical resistivity. When caries occur, the porosities in dental hard tissue increase in size and contain more electrically conductive fluids from the oral cavity compared with the sound tooth. Since the porosities are filled with this ionic fluid, there is a decrease in electrical resistance and an increase in electrical conductance.

24. Electrical Conductance Measurement The electrical conductance measurement device uses a single, fixed-frequency alternating current to measure the electrical conductance of a carious tooth . The measuring electrode is designed to fit into deep pits and fissures to be in contact with a minuscule amount of dentinal fluid to complete the circuit No carious lesions -current flow cannot be completed- Reading-zero. If a lesion is present-current flow would present -reading will be in the device ADVANTAGES Detection of both non-cavitated and cavitated caries lesions on occlusal, proximal, and smooth surfaces. Assessment of caries severity with a quantitative approach(loss of minerals and increased porosities) Can differentiate caries and stains DISADVANTAGES : Under research

25. Alternating Current Impedance Spectroscopy Alternating current impedance spectroscopy measures the impedance or the resistance of the teeth to alternating current. This detection method utilizes multiple frequencies of electricity to produce a spectrum of values, providing more information on the physical and chemical properties of a tooth A sensing brush can be moved over the suspected carious site, providing a numerical reading supplemented by a colour code that indicates the probability of caries . This method can detect carious lesions at early stages.

26. Ultrasound-Based Diagnostic Aids It detects the difference between sound and demineralized hard tissue through the sonic conductivity of longitudinal ultrasonic waves. It utilizes ultrasonic waves which can be transmitted on smooth, flat, or curved hard tissue surfaces.

27. Ultrasonic Caries Detector The ultrasonic probe of the ultrasonic caries detector can be placed at a certain angle to detect caries lesions, particularly proximal carious lesions. ADVANTAGES Adequate directionality High penetration level Non-toxicity

28. Digital Diagnostic Aids under Development Optical coherence tomography Laser-induced thermal imaging Frequency-domain laser infrared photothermal radiometry and modulated luminescence technology Laser-induced breakdown spectroscopy Laser-induced acoustic spectroscopy Automatic exposure compensation (AEC) Artificial intelligence Deep learning of dental caries- cbct Short tau inversions recovery (STIR) sequence Terahertz technology Intraoral scanners and near-infrared imaging technology Short-wave infrared (SWIR) Cp-oct Photoacoustic imaging (PAI) - a new imaging method

29. OCT

30. DEEP LEARNING OD DENTAL CARIES- CBCT Convolutional neural networks (CNNs) are a type of deep learning model based on neural networks in artificial intelligence that are used for image classification and object detection in images. CNNs can detect dental caries and analyse dental images to identify caries regions. They can identify dental caries signs in images, enabling early caries detection using trained neural networks.

31. Occlusal caries detected on the CBCT radiographs were labelled as type I, proximal caries a type II, caries in the cervical region as type III, and teeth with more than 1 caries as type IV. For classification of the caries extension, there were the following 3 classes: “D1” caries had radiolucency in enamel or the outer third of dentin; “D2” caries had radiolucency in the middle third of dentin; and “D3” caries had radiolucency in the inner third of dentin with or without apparent pulp involvement

32. Esmaeilyfard R, Bonyadifard H, Paknahad M. Dental Caries Detection and Classification in CBCT Images Using Deep Learning. Int Dent J. 2024 Apr;74(2):328-334

33. ADVANTAGE deep learning is a precise and highly efficient tool for detecting dental caries. CNNs can provide dental caries detection at much lower costs than dental examinations. Considering the shortage of dentists in certain areas, using CNNs can lead to broader geographic coverage in detecting dental caries Deep learning can provide dental caries detection accurately.

34. DISADVANTAGE CNNs for dental caries detection requires accurate translation of radiographic data and training the networks with sufficient and diverse datasets. This method still requires further refinement and improvement. Additionally, this approach requires more complex equipment and powerful processing capabilities, which may not be readily available in some dental centers. In addition, the images used during the training process must be labeled by experts.

35. Short tau inversions recovery (STIR) sequence In the STIR sequence, carious lesions presented as a hyperintensity compared to the surrounding healthy hard tissue The use of a water-sensitive STIR sequence allowed for detecting signifcantly lower to high pulp signal to noise ratios in carious teeth. This could image the various levels of disease activity of in-vivo carious processes. Recently, the transition from regular MRI to dental dedicated MRI is given where the use of intra-oral coils specifically designed for dental applications which allows optimizing diagnostic accuracy, with regard to image quality Burian E, Lenhart N, Greve T, Bodden J, Burian G, Palla B, Probst F, Probst M, Beer M, Folwaczny M, Schwarting J. Detection of caries lesions using a water-sensitive STIR sequence in dental MRI. Scientific Reports. 2024 Jan 5;14(1):663.

36. Terahertz technology Terahertz ( thz ) radiation, which is also recognized as thz waves or thz light is located between the high-frequency microwave region and the long-wavelength far-infrared region of the electromagnetic spectrum. THz parametric imaging (TPI) has great potential for medical applications as it is a non-destructive imaging method. by using the THz time-domain spectroscopy (THz-TDS) based methods to analyze the changes in absorption and refractive indexes, significant differences were found between permanent and primary teeth and between health and primary teeth. This technique has also shown promise in measuring the effects of mineralization and demineralization

37. Nagendra Paradad Yadav, Guo-Zhen Hu, Zheng-Peng Yao, Ashish Kumar,Diagnosis of dental problem by using terahertz technology,Journal of Electronic Science and Technology,Volume 19, Issue 3,2021

38. Intraoral scanners and near-infrared imaging technology (NIR) Intraoral scanners are also showing promise in caries detection using near-infrared (NIR) and fluorescent technology. Caries detection using NIR is based on the principle that varying tooth structure interacts with infrared light in different ways. When the infrared light of this wavelength illuminates the tooth structure, it reduces scattering and absorption of light and enables deeper penetration of the light into the solid enamel which is presented as a darkly transparent object. Dentin appears bright due to the scattering of light caused by the random orientation of dentinal tubules, and areas of demineralization appear bright due to the scattering of light within the area .

39. One intraoral scanner system (iTero Element five-dimensional) utilizes light of 850 nm wavelength, whereas, another intraoral scanner system (Trios 4 and 5) utilizes a shorter wavelength of 727 nm for caries detection. Different scanning tips in an intraoral scanner system Caries detection using NIR

40. Lin WS, Alfaraj A, Lippert F, Yang CC. Performance of the caries diagnosis feature of intraoral scanners and near-infrared imaging technology-A narrative review. J Prosthodont . 2023 Dec;32(S2):114-124.

41. Short-wave infrared (SWIR) SWIR light allows transparent enamel imaging, enabling occlusal transillumination—capturing images of the tooth from its biting surface or below the gum line . Early caries detection and assessing cavity severity without ionizing radiation. SWIR imaging offers high sensitivity, it poses challenges with false positives like glares and hypomineralization , potentially mistaken for dental decay

42. CP-OCT: A non-invasive dental imaging technique a non-invasive imaging technique utilizing polarized light to generate 3D tooth images enhances image contrast, allowing for detailed visualization of the tooth’s cross-sectional anatomy. identifies root and coronal caries, cementum loss, and severe demineralization at the root surface enables the identification of the transparent remineralized surface layer that forms atop dental caries Yihua Zhu (2024), "The future of dentistry: Exploring the latest advancements in dental imaging", Open Access Government April 2024, pp.102-103

43. Kashirtsev F, Simon JC, Fried D. Imaging dental fluorosis at SWIR wavelengths from 1300 to 2000-nm. InPhotonic Therapeutics and Diagnostics in Dentistry, Head and Neck Surgery, and Otolaryngology 2021 Mar 5 (Vol. 11627, pp. 49-54). SPIE. ( Komaki, Aichi, Japan)

44. Photoacoustic imaging (PAI) is a non-invasive biological imaging technique that unifies the benefits of optical and sound imaging. Thus, PAI in dentistry is expected to be a non-invasive, radiation-free mode of dental and oral examination with high spatial resolution, rapid image acquisition, and affordable cost The photoacoustic effect, which is the basic principle of PAI, involves illuminating a substance or tissue with an modulated laser wave. Photoacoustic imaging (PAI) - a new imaging method

45. The tissue absorbs the light pulse, resulting in thermoelastic expansion and consequent wave propagation. PAI is distributed into two subfields: photoacoustic microscopy (PAM) and photo acoustic tomography (PAT); the latter of which allows for in vivo imaging. Using an array detector, the produced acoustic waves from the medium’s surface can be detected in PAT. The distribution of tissue optical absorption illuminated by laser in PAI is then calculated for image reconstruction using the sound waves received from the detector. With simple changes, beamforming algorithms and techniques frequently employed in ultrasound (US) imaging can be applied to PAI Sari AW, Widyaningrum R, Setiawan A. Recent development of photoacoustic imaging in dentistry: A review on studies over the last decade. The Saudi Dental Journal. 2023 Jul 1;35(5):423-36.

46. The tissue absorbs the light pulse, resulting in thermoelastic expansion and consequent wave propagation The laser-induced photoacoustic effect was initially used in dentistry to detect dental caries ; a Q switched Nd:YAG laser (1064 nm) was used to produce a measurable reaction in the teeth. A piezoelectric transducer and a Michelson interferometer were employed as detectors, both of which responded identically to the carious and healthy teeth.

47. Digital imaging in endodontics

48. CBCT It is also known as Dental volumetric tomography, Cone beam volumetric tomography, dental computed tomography and cone beam imaging. • It uses a divergent or “cone“ shaped source of ionizing radiation (conical or pyramidal) and a 2D area detector fixed on a rotating gantry to acquire multiple sequential projection images in one complex scan around the area of interest.

49. The X-ray source and the detector rotate between 180° to 360° around the patient’s head, depending on the CBCT scanner used. Resulting dataset is then computer-aided reconstructed in 3D pixels (voxels), which account for around 100 million voxels. Cone beam instead of a fan-shaped beam, acquiring images of entire volume. Entire 3-dimensional volume of data of the patient Single revolution of the x-ray source and detector . Endodontic imaging-recent advances: a review, Dr. Swati Bhosale Dr. M Rameshkumar, INTERNATIONAL DENTAL JOURNAL OF STUDENT’S RESEARCH, April 2016

50. VOXEL In CBCT, a voxel is defined as the smallest viewable part, represented by a cube , which the digital 3D image data can be divided into (the smallest 3D element of the volume). For CBCT, voxels are isotropic, and their size is directly related to image quality and reconstruction time Smaller voxel sizes are related to higher resolution, higher radiation dose, and longer reconstruction time, but also a greater possibility of occurrence of artifacts Voxel values between 76 μm to 300 μm are therefore recommended for endodontics, given the structural characteristics of the dentine pulp complex and periapical tissues

51. Field of view (FOV) The FOV refers to the anatomical area—measured in mm—that will be included in the volume of data or the area that will be subjected to radiation . PRINCIPALLY INFLUENCED detector’s size and shape Beam projection geometry, and Beam collimation capability Smaller the scanning volume, the higher the spatial resolution of the image, and the lower the radiation dose and the reconstruction time needed, Small FOVs are recommended for diagnosis and treatment in endodontics with enhanced quality of image

52. CBCT CLASSIFICATION

53. Ríos-Osorio N, Quijano- Guauque S, Briñez -Rodríguez S, Velasco- Flechas G, Muñoz-Solís A, Chávez C, et al . Cone-beam computed tomography in endodontics: from the specific technical considerations of acquisition parameters and interpretation to advanced clinical applications. Restor Dent Endod 2024;49(1):e1.

54. CLINICAL APPLICATIONS IN ENDODONTICS DIAGNOSIS PRE-OPERATIVE INTRAOPERATIVE AND POST OPERATIVE ASSESSMENT TREATMENT PLANNING Normal root anatomy Anatomical anomalies Apical periodontitis Periapical lesions Trauma Vertical root fracture Root resorption Initial RCT Guided Endodontics Retreatment Presurgical planning for RCT Material extrusion beyond root canal Fractured instruments Perforations Assessment of outcomes Patel S, Brown J, Pimentel T, Kelly RD, Abella F,Durack C. Cone beam computed tomography in Endodontics – a review of the literature. International Endodontic Journal, 52, 1138–1152, 2019

55. ADVANTAGES OF CBCT Kiarudi AH, Eghbal MJ, Safi Y, Aghdasi MM, Fazlyab M. The applications of cone-beam computed tomography in endodontics: a review of literature. Iran Endod J. 2015 Winter;10(1):16-25 . Images of highly contrasting structures Multiplanar reformation Cost effective Rapid Scan time Beam Limitation Interactive display modes applicable to maxillofacial imaging Image accuracy Reduced patient radiation dose Three dimensional Volume Rendering

56. DISADVANTAGES Scanner-related artifacts Cone beam related artifacts (1) partial volume averaging. (2) undersampling (3) cone-beam effect. Patient related artifacts X-ray beam artifacts Image noise • Poor tissue contrast Shaul Hameed Kolarkodi , The importance of cone-beam computed tomography in endodontic therapy: A review, The Saudi Dental Journal, Volume 35, Issue 7, 2023

57. AAE and AAOMR Joint Position Statement- Use of CBCT in Endodontics The AAE and the AAOMR suggested “ CBCT should not be used for routine endodontic diagnosis or for screening purposes in the absence of symptoms”. For most endodontic applications, limited FOV CBCT is preferred to medium or large FOV CBCT because there is less radiation dose to the patient, higher spatial resolution and shorter volumes to be interpreted.

58. DIAGNOSIS OF CONTRADICTORY OR NON SPECIFIC SIGNS AND SYMPTOMS PRE-, INTRAOPERATIVE CONDITIONS LIKE MISSED , EXTRA CANALS POSTOPERATIVE HEALING SURGICAL AND NON SURGICAL CASES , VERTICAL ROOT FRACTURE, OUTCOME ASSESSMENT Mohamed I. Fayad , Madhu Nair, Martin D. Levin, Erika Benavides, Richard A. Rubinstein, Sevin Barghan , Craig S. Hirschberg, Axel Ruprecht, AAE and AAOMR Joint Position Statement: Use of Cone Beam Computed Tomography in Endodontics 2015 Update,Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology,Volume 120, Issue 4,2015

59. DOSAGE – DENTAL PROCEDURES INTRA ORAL – 0.001 MSV UPTO 0.004MSV FULL MOUTH SET – 0.080MSV LATERAL CEPHALOGRAM – 0.002MSV DENTAL PANAROMIC TECHNIQUE – 0.015MSV CBCT (BOTH JAWS) – 0.068MSV HOSPITAL CT SCAN (BOTH JAWS) – 0.6MSV Jaju PP, Jaju SP. Cone-beam computed tomography: Time to move from ALARA to ALADA. Imaging Sci Dent. 2015 Dec;45(4):263-5. Concept of "as low as reasonably achievable" (ALARA) to "as low as diagnostically acceptable" (ALADA)

60. CBCT FOR EXTERNAL CERVICAL RESORPTION Cone beam computed tomography improves the diagnosis and/or management of ECR by providing essential three-dimensional information about the nature and extent of the lesions, the degree of circumferential spread and proximity to the root canal. The Patel classification is a three-dimensional assessment of ECR based on periapical radiographs and CBCT.

61. Patel S, Krastl G, Weiger R, Lambrechts P, Tjäderhane L, Gambarini G, Teng PH. ESE position statement on root resorption. Int Endod J. 2023 Jul;56(7):792-801. 

62. COMPUTED TOMOGRAPHY Godfrey Hounsefield 1972 - computerized axial tomography Computed tomography is an imaging technique which produces three-dimensional images of an object by taking a series of twodimensional sectional X-ray images. Madhu K. Nair, Umadevi P. Nair, Digital and Advanced Imaging in Endodontics: A Review, Journal of Endodontics, 2007

63. MICRO COMPUTED TOMOGRAPHY Uses stacked fan-beam geometry and produces 3D reconstruction of the objects examined. • Desktop micro-CT used to reconstruct root canals without requiring a previous disassembly of the teeth. It allows the use of the same sample for different tests without destruction of the sample. This characteristic is very important particularly when is required to evaluate volume pre and post instrumentation, quality of root canal instrumentation, obturation or removal of the material from root canal (retreatment). Radiation level of exposure restricts its use for in vivo studies . Also, micro-CT permits the examination of specimens of limited size, which restrict some analysis. Madhu K. Nair, Umadevi P. Nair, Digital and Advanced Imaging in Endodontics: A Review, Journal of Endodontics, 2007

64. MICRO COMPUTED TOMOGRAPHY NeoScan Tabletop/Desktop Micro-CT or Micro Computed Tomography System

65. TUNED APERTURE COMPUTED TOMOGRAPHY(TACT) Consists of: Standard radiographic unit Digital image device TACT software Uses Vertical root fractures even without displacements Visualization of canals better than conventional radiographs Detection of secondary caries Diagnosis of external root resorption Pankil Shah & Komal Zalavadia . Recent Advances in Dental Imaging. Sch J Dent Sci, 2021 July 8(6): N/A.

66. SPIRAL COMPUTED TOMOGRAPHY SCT or volume acquisition CT, employs simultaneous patient translation through the x-ray source with continuous detection of the source detector assembly. • This data can be viewed as multiplanar reconstruction or as 3Dreconstructions. • It is possible to reconstruct overlapping structures and examine at smaller scales .

67. OPTICAL COHERENCE TOMOGRAPHY OCT is a relatively new diagnostic imaging technology introduced in 1991. • Non-invasive technique which gives high resolution images. • OCT uses infrared light waves of wavelength of 1300nm, that reflect off the internal microstructure within the biological tissues. • OCT is based on low coherence interferometry (LCI) and achieves micron scale cross-sectional images. Batool P, Chaudry MZ, Irfan U, Khero R, Khan MS, Farrukh U. Novel Imaging Techniques for Early Detection of Dental Caries. Korean Journal of Physiology and Pharmacology. 2023 Dec 5;27(4):474-80.

68. Optical Coherence Tomography RS-3000 Advance 2

69. ULTRASOUND Ultrasound is a non-ionizing, non-invasive, real-time, and chairside modality that provides cross-sectional images for the evaluation of soft and hard tissue. It uses acoustic waves that are coupled and transmitted into the human body and scattered back or reflected to the transmitter as they encounter tissue interfaces Ultrasound images can either be acquired as sole anatomical images (B-mode) or with additional physiological information, such as blood flow (using color flow (CF) mode as well as pulse-wave mode (PW)). • It assess nature and dimension of lesion, high sensitivity and specificity of ultrasound to diagnose periapical cysts and granulomas which helps in preoperative assessment and treatment planning Shah N, Bansal N, Logani A. Recent advances in imaging technologies in dentistry. World J Radiol . 2014 Oct 28;6(10):794-807 .

70. Ultrasound device prototype, probe shaped as a dental hand piece and PZT transduce

71. MAGNETIC RESONANCE IMAGING Magnetic resonance is a completely non-invasive technique since it uses radio waves. It also allows acquisition of direct views of the body in almost all orientations. Its best performance is in showing soft tissues and vessels whereas it does not provide great details of the bony structures. Amanda Pelegrin Candemil , Guilherme Nilson Alves dos Santos, Matheus L. Oliveira, Filippo Gatti , Yara T.C. Silva-Sousa, Alice C. Silva-Sousa, Jardel Francisco Mazzi -Chaves, Manoel Damião Sousa- Neto , Accuracy of Magnetic Resonance Imaging in Clinical Endodontic Applications: A Systematic Review,Journal of Endodontics,2024

72. MRI scans are not affected by artefacts caused by metallic restorations (for example amalgam, metallic extra coronal restorations and implants) which can be a major problem with CT technology. Pulpal remnants, abscess and expanding periapical lesion or any other soft issue analysis could be easily achieved.

73. Luxation injuries and other stimuli may lead to a pulp canal obliteration (PCO). Even though the apposition of tertiary dentine is a sign of a vital pulp, in some cases root canal treatment is indicated in the long term due to apical periodontitis or pulpitis which will be challenging for endodontists to perform. The ‘guided endodontics ’ (GE) technique was introduced 6 years ago as an alternative to conventional access cavity preparation for teeth with PCO and apical pathosis or irreversible pulpitis. Krastl et al (2016) conducted the first scientific report on GE in a clinical case report where the authors used this technique to access the calcified pulp chamber of an upper central incisor with apical periodontitis Connert T, Weiger R, Krastl G. Present status and future directions - Guided endodontics. Int Endod J. 2022  system.  GUIDED ENDODONTICS

74. Guided Endodontics with coDiagnostiX ® - Dental Wings

75. Krastl et al (2016) conducted the first scientific report on GE in a clinical case report where the authors used this technique to access the calcified pulp chamber of an upper central incisor with apical periodontiti Using three‐dimensional radiological imaging such as cone‐beam computed tomography and a digital surface scan, an optimal access to the orifice of the calcified root canal can be planned virtually with appropriate software. (Blue Sky Bio) GE is implemented either with the help of templates( stereolithography template over epoxy resin model) analogous to guided implantology (= static navigation) or by means of dynamic navigation based on a camera‐marker. Krastl G, ZehnderMS,ConnertT,etal.Guidedendodontics:anoveltreatmentapproachforteeth with pulp canal calcification and apical pathology. Dent Traumatol 2016;32:240–6 .

76. Dąbrowski W, Puchalska W, Ziemlewski A, Ordyniec-Kwaśnica I. Guided Endodontics as a Personalized Tool for Complicated Clinical Cases. Int J Environ Res Public Health. 2022 Aug 12;19(16):9958.

77. REAL-TIME 3-DIMENSIONAL DYNAMIC NAVIGATION SYSTEM Endodontic microsurgery (EMS) is a treatment option for root canal-filled teeth with persistent apical periodontitis. EMS involves several steps, including flap reflection, osteotomy, root end resection (RER) ( ie , apicoectomy), root end cavity preparation (RECP), and root end fill (REF) The 3-dimensional dynamic navigation system (3D-DNS) is an emerging technology that delivers minimally invasive procedures with improved accuracy and safety while avoiding catastrophic mishaps. This novel technology is a computer-based system similar to satellite-guided navigation.

78. The 3D-DNS guides a clinician in real time based on an information plan generated from a patient’s CBCT images. The 3D-DNS system also uses motion tracking optical cameras and CBCT images of the position of the virtually planned surgery. This provides real-time 3-dimensional (3D) dynamic navigation plus visual feedback to guide surgical instruments intraoperatively. Aldahmash SA, Price JB, Mostoufi B, Griffin IL, Dianat O, Tordik PA, Martinho FC. Real-time 3-dimensional Dynamic Navigation System in Endodontic Microsurgery: A Cadaver Study. J Endod . 2022

79. Thomas Connert , Wadim Leontiev , Dorothea Dagassan -Berndt, Sebastian Kühl , Ashraf ElAyouti , Ralf Krug, Gabriel Krastl , Roland Weiger , Real-Time Guided Endodontics with a Miniaturized Dynamic Navigation System Versus Conventional Freehand Endodontic Access Cavity Preparation: Substance Loss and Procedure Time, Journal of Endodontics,2021 3D-DNS technology has been successfully tested for locating calcified canals, access cavities, post removal, endodontic retreatment, and intraosseous anesthesia.

80. X- GUIDE, X- NAV TECHNOLOGIES, INC, LANSDALE, PA, USA

81. NAVIDENT Navident is a computer-aided dental surgery technology that uses cone beam 3D imaging and software to help surgeons plan and perform dental procedures.  Dental implants Jaw surgeries Flapless surgery

82. COMPONENTS: MT4 Camera High optical resolution camera. 175 degrees of horizontal and 90 vertical range 360 Hand Piece Tracker All quadrants can be precisely and consistently accessed by any hand piece mounted with our 360 adapter and tracker. “ Impression Registration Fiducial registration. “Instant” Registration requires 1 minute of additional preparation time before the scan and saves minutes of valuable chair time. Trace Registration By virtue of MT4 camera, our trace registration tag shrinks to the size of a pen. Easy to manipulate around incisal edges and palatal/lingual surfaces,

83. Vasudevan A, Santosh SS, Selvakumar RJ, Sampath DT, Natanasabapathy V. Dynamic Navigation in Guided Endodontics - A Systematic Review. Eur Endod J. 2022 Jun;7(2):81-91. doi : 10.14744/eej.2022.96168. PMID: 35786584; PMCID: PMC9285996.

84. X-Guide is a dynamic navigation system developed - by X-Nav Technologies and now sold by Nobel Biocare , that assists clinicians in placing dental implants. The system uses 3D imaging and real-time navigation technology to provide visual guidance during implant placement procedures. It is a complete package with tracking hardware and the DTX implant planning software suite.

85. Components of the X-Guide Navigated Implant System X-Guide cart with overhead Blue- OptiX LED lights, Stereo cameras and live navigation screen. X-Clip with X-Point tracking system. Calibration disc for handpiece, calibration plate for drills/implants and X-Mark Probe. Surgical handpiece with proprietary X-Point tracking pattern.

86. A llows dentists to locate and access endodontic tooth structures more precisely. Less invasive access and prep of calcified and hidden canals, while perform minimally invasive apicoectomy and root-end access and minimize damage to anatomical structures. preserve tooth structure, saving time and potentially reduce intra-operative imaging A Revolutionary Protocol for Endodontic Access Drs. L. Stephen Buchanan, Charles Maupin, and John Khademi

87. DENAMARK SYSTEM RTGE setup: (E ) a 3D-printed tray containing (F ) a DENAMARK marker is positioned on (D ) a study model and mounted in (C ) a dental mannequin. (B ) The DENACAM system connected with a computer and (A ) the necessary software provides 3D dynamic navigation during access cavity preparation. Real-Time Guided Endodontics with a Miniaturized Dynamic Navigation System Versus Conventional Freehand Endodontic Access Cavity Preparation: Substance Loss and Procedure Time

88. Real-Time Guided Endodontics with a Miniaturized Dynamic Navigation System Versus Conventional Freehand Endodontic Access Cavity Preparation: Substance Loss and Procedure Time

89. Do not forget the roots - Digital radiograph ALARA shifted to ALADA Early caries detection using the recent advances – better the treatment outcome AI the new trend Real-time dynamic navigation system the current vogue To enhance the treatment outcome.