Multi-Modality Endodontics with 3D Imaging —What to Look for in a New Imaging Unit

By Brian Trava, DMD, PA

Fig. 1–Bilateral imaging, along with an implant library, adds to the ease of computer-guided implant treatment planning

As an endodontist in New Jersey, I know the standard of care in my profession is changing dynamically in relation to the technology that is available. Researching and investing in the right technology allows dentists the full potential to practice the complete spectrum of endodontics.

Cone Beam Computed Technology (CBCT) 3D imaging has been repeatedly mentioned by our professional associations and various authors as a new standard. It is a conduit to advancing the specialty of endodontics, raising our high standards of excellence and providing enhanced comprehensive oral health care to our patients. Having the right technology, such as CBCT 3D imaging, allows your practice to provide superior diagnosis and guidance to fellow medical and dental professionals.

There has been a rapid influx of 3D imaging machines on the market, but not all machines are right for every practice. If you have done more research on a new car purchase than you’ve done on a CBCT, you may be missing out on some key features that will be beneficial to your practice. After all, your car won’t return your investment like your CBCT machine will.

Fig. 2–Traditional 2D PA film

I thought it would be helpful to my fellow dentists and Henry Schein readers to share what I discovered during my research for a 3D imaging unit.

What is Multi-Modality Endodontics?

Multi-modality endodontics (MME) is the use of multi-modality imaging machines to treat our endodontic patients. Having the specific strengths of several complementary imaging modalities and software has numerous advantages in the assessment and treatment of our patients. We become more comprehensive in aiding our colleagues. Saving our natural dentition is the most important task, but diagnosing and treating the surrounding oral facial structures is just as important.

A Multi-modality machine (MMM) allows for 2D imaging, 3D imaging, a true panorex, periapical imaging, and a true “Super Bitewing.” The 3D imaging should have the flexibility to go from large to small volume, but most of all bilateral. The imaging modalities should be flexible enough to view any area of the oral maxillary complex, including TMJ and sinus. I find it very useful for the software to have an implant library and the capability to place them (see Figure 1).

Fig. 3–3D section from 3D rendering

Comprehensive Treatment

A good MMM will have the capability to render varying size 2D and 3D images. If radiation exposure is an issue, the machine should have the ability to blend a variety of mA/kV and be able to apply them in multiple-size 2D or 3D images. Please make sure your salesman or dealer is specific about these.

A good CBCT 3D imaging unit should be able to help you better diagnose pain.

Fig. 4–Traditional Panorex from the same MMM

Many machines are focused only on needing a small volume (3×5). A good MMM is not limited. It has the advantage of rendering a small single tooth scan and the ability to do a bilateral or full scan. If the patient has a lifetime of dental restorations or is anticipating work in a future treatment plan, having a one-time CBCT scan has many advantages:

  • Increased success with treating current endodontic teeth.
  • Knowledge of all root morphology for future endodontic treatment.
  • Diagnosing incipient issues, a cost savings to the patient.
  • Bilateral is more comprehensive for implant placement and guide fabrication. It is expensive for the practitioner and patient.
  • Less radiation and less time consuming to do one scan rather than multiple small volume scans.

Fig. 5–3D rendering of a large radiolucent area

Prescreening for medical procedures is a simple task with the right MMM. Many physicians look to our office to rule out any major dental issues, especially pertaining to chronic infections (see Figures 2 & 3). In my experience, this means patients who are undergoing radiation treatment, Fosamax treatment, cardiac, orthopedic, and organ transplant. A bilateral volume is the most efficient rendering to have completed, and a 3D imaging machine that handles only small volume requires you to take multiple volumes. This adds up to a larger overall dose of radiation with more difficulty quantifying and sending out diagnostic information.

Fig 6.–Extraoral bite wing

Diagnosing Pain

A good CBCT 3D imaging unit should be able to help you better diagnose pain. In some cases, pain that appears to be acute, chronic, stimulated, unstimulated, diffuse, or site specific on first instinct may be odontogenic in origin. Diagnosing non-odontogenic pain falls within the comprehensive treatment of MME. Obtain a broad picture of the target area, and then focus with more detail using a 3D rendering. We have the technology to comprehensively examine our patient to assist the general practitioner in a more thorough direction to give them an end point. From the inception, our profession has based our radiographic interpretation and diagnosing on traditional 2D imaging (see Figure 4). With the introduction of 3D imaging, lesions and surrounding anatomical structures have a distinct difference (see Figure 5). It’s a definitive advantage to diagnose with both capabilities, so look for this comprehensive spectrum when you shop for your next 3D imaging unit.

Fig. 7–Select segment program

A MMM should have the following programs:

  • Extraoral bite wing (see Figure 6)
  • Panorex adjustable rate
  • Segmented panorex (see Figures 7 & 8)
  • Interproximal panorex

The extraoral bitewing accomplishes three things:

  1. Captures left and right sides
  2. Captures the apexes
  3. Separates the contacts with no overlap

An adjustable-rate panorex allows the midline not to be distorted, allowing for more diagnostic capability to circumvent radiographs inside the mouth. A segmented panorex allows certain target areas of interest to be taken and other areas to be excluded.

The interproximal panorex will separate the contacts to enhance the diagnostic capabilities of decay detection as well as the full oral cavity.

The radiographic information can be forwarded to the general practitioner for completion of the treatment plan, a cost- effective, time-saving, and beneficial service for the patient and referring doctor.

Fig. 8–Focused periapical film panorex mode


Many CBCT machines are entering the market. Knowing which machine is right for your practice requires a bit of research. Go beyond the salesperson who visits the office and decide what you want to achieve and how you want to grow your practice. Look to a company and MMM that will grow over time with your practice. In the long run, it will be more cost effective, more rewarding intellectually, and it will provide a more complete service for your patients.

Brian Trava, DMD, PA is an endodontist in Hawthorne, N.J. He currently uses a PLANMECA ProMax Imaging Unit. For more information, please visit