Dr. Roberto Aza
Dr Roberto Aza graduated with a Dental Degree from ISCS-SUL, Lisbon (1990–1996). He completed postgraduate training in Clinical Endodontics and Microsurgery at the Centro de Odontología Microscópica in Bilbao under the direction of Dr Borja Zabalegui (2004–2005), followed by a Master’s Degree in Endodontics at UEM (2010–2012).
In 2017 he was awarded a PhD in Dentistry from Universidad Alfonso X. Dr Aza is a member of the Spanish Association of Endodontics (AEDE) and an Associate Member of the American Association of Endodontists (AAE). He currently works in private practice in Madrid with a special focus on endodontics.
introduction
introduction
Advances in digital imaging continue to transform modern endodontics, enabling clinicians to diagnose and manage complex anatomical variations with greater confidence and precision. Cone-Beam Computed Tomography (CBCT) has become an essential diagnostic tool when conventional radiography does not provide sufficient information.
This case study highlights how CBCT imaging was used to identify complex root canal anatomy and guide successful treatment planning in a challenging endodontic case.
Patient Presentation
Patient Presentation
A 44-year-old male patient was referred with a history of pain in the left maxillary posterior region. Initial periapical radiographic examination revealed extensive caries associated with teeth 2.6 and 2.7.
Clinical examination demonstrated:
- Negative responses to palpation and percussion
- Sensibility testing confirming a diagnosis of symptomatic irreversible pulpitis in tooth 2.7
Although the initial radiograph suggested pathology, the root canal morphology could not be clearly visualised.
Diagnostic Challenges
Diagnostic Challenges
Maxillary molars are known for their anatomical complexity and variability. Conventional two-dimensional radiographs may not always reveal additional canals or unusual root configurations.
Because the periapical radiograph did not clearly show the canal morphology, further imaging was considered.
According to the 2025 joint position statement from the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR), limited field-of-view (FOV) CBCT imaging is recommended when:
- Conventional radiographs are inconclusive
- Complex root canal anatomy is suspected
- Three-dimensional imaging may influence treatment planning
CBCT imaging has been shown to provide improved diagnostic accuracy when identifying additional canals and evaluating periapical pathology compared with conventional radiography.
Importantly, the use of limited FOV CBCT imaging follows ALARA (As Low As Reasonably Achievable) principles, ensuring that radiation exposure is minimised while obtaining clinically relevant diagnostic information.
“The use of limited FOV CBCT imaging follows ALARA principles, ensuring that radiation exposure is minimised while obtaining clinically relevant diagnostic information.”
Advanced Imaging and Certified CBCT Technology
Advanced Imaging and Certified CBCT Technology
In this case, Dr. Roberto Aza utilised CBCT imaging as part of his diagnostic workflow using technology from Carestream Dental’s certified CBCT portfolio.
The portfolio — which includes systems such as the CS 9600 and CS 8200 3D family — is the first CBCT imaging range to receive official certification from the Digital Dentistry Society (DDS). This certification follows a comprehensive evaluation by international academic experts and assesses technologies across several key areas, including diagnostic image quality, scientific validation, and integration within digital dental workflows.
Independent certification helps ensure clinicians can rely on high-quality imaging performance and diagnostic reliability when managing complex clinical situations such as challenging endodontic anatomy.
By combining CBCT imaging with advanced visualisation and planning tools, clinicians can gain a more detailed understanding of root canal morphology and improve treatment predictability in difficult cases.
Three-Dimensional Treatment Planning
Three-Dimensional Treatment Planning
Using the CBCT dataset, virtual treatment planning was performed with specialised three-dimensional imaging software that incorporated a root canal tracing tool.
This enabled a comprehensive preoperative assessment of the tooth and allowed the clinician to:
- Visualise root canal morphology in three dimensions
- Plan the access cavity more accurately
- Identify additional canals
- Reduce the risk of procedural complications
Such complications can include perforation, missed canals, or instrument separation during treatment.
Clinical Treatment
Clinical Treatment
Endodontic treatment was carried out under magnification using an operating microscope.
During the procedure, intraoperative findings confirmed the CBCT diagnosis: two canals were present in the palatal root of tooth 2.7, a variation that was not visible on the initial radiograph.
Post-operative periapical radiographs demonstrated satisfactory obturation of all identified canals.
Long-Term Outcome
Long-Term Outcome
A two-year follow-up radiographic evaluation demonstrated:
- Maintenance of periapical health
- Absence of clinical symptoms
- A successful treatment outcome
The follow-up confirmed that identifying the additional canal during the initial treatment was critical to achieving long-term clinical success.
Discussion
Discussion
Successful endodontic treatment depends on accurate diagnosis and complete identification of the root canal system. Failure to detect anatomical variations remains a significant cause of endodontic treatment failure.
A growing body of research demonstrates the advantages of CBCT imaging in endodontic diagnosis.
Studies have shown that:
- CBCT provides improved diagnostic accuracy for identifying apical periodontitis compared with periapical radiography
- Additional periapical lesions can be detected with CBCT that may not be visible using conventional imaging
- CBCT is particularly valuable in complex cases where conventional radiographs provide limited information
The AAE/AAOMR joint position statement recommends CBCT imaging in situations including:
- Identification of additional canals or unusual root canal configurations
- Evaluation of teeth with suspected complex anatomy
- Assessment of non-healing cases
- Situations where conventional imaging does not provide adequate diagnostic information
However, the guidelines emphasise that CBCT should not be used routinely, but selectively in cases where the additional diagnostic information will directly influence treatment planning and patient care.
In this case, the three-dimensional imaging data significantly influenced the treatment approach and prevented a potentially missed canal.
conclusion
conclusion
This case demonstrates the important diagnostic value of limited field-of-view CBCT imaging in identifying complex root canal anatomy that cannot always be detected with conventional two-dimensional radiography.
When used appropriately and in accordance with professional guidelines, CBCT can:
- Enhance diagnostic accuracy
- Improve treatment planning
- Reduce procedural risks
- Contribute to successful clinical outcomes
Adhering to ALARA principles and using targeted imaging ensures that clinicians obtain essential diagnostic information while minimising patient radiation exposure.
NOTES
CARESTREAM DENTAL IMAGING
Dr. Roberto Aza chooses Carestream Dental imaging for its high quality and reliability at his dental office.