60673

Download the full version of the ebook at ebookfinal.
com
Cone Beam Computed Tomography in Endodontics 1º

Edición Edition Shanon Patel
https://ebookfinal.com/download/cone-beam-computed-
tomography-in-endodontics-1o-edicion-edition-shanon-patel/
OR CLICK BUTTON
DOWNLOAD EBOOK
Download more ebook instantly today at https://ebookfinal.com

Instant digital products (PDF, ePub, MOBI) available
Download now and explore formats that suit you...
The Principles of Endodontics 2nd Edition Shanon Patel

(Editor)
https://ebookfinal.com/download/the-principles-of-endodontics-2nd-
edition-shanon-patel-editor/
ebookfinal.com
MacMillan Destination C1 C2 Grammar Vocabulary Malcolm

Mann
https://ebookfinal.com/download/macmillan-destination-c1-c2-grammar-
vocabulary-malcolm-mann/
ebookfinal.com
Kalender Willi A Computed Tomography 3rd edition Publicis

Publishing & Erlangen (Www.Publicis-Books.De)
https://ebookfinal.com/download/kalender-willi-a-computed-
tomography-3rd-edition-publicis-publishing-erlangen-www-publicis-
books-de/
ebookfinal.com
Theory of Beam Columns Volume 1 In Plane Behavior and

Design J Ross Publishing Classics Wai-Fah Chen
https://ebookfinal.com/download/theory-of-beam-columns-volume-1-in-
plane-behavior-and-design-j-ross-publishing-classics-wai-fah-chen/
ebookfinal.com
The Practice of Shiatsu 1e 1 Pap/DVD Edition Sandra K.
Anderson Ba Lmt Abt Nctmb
https://ebookfinal.com/download/the-practice-of-shiatsu-1e-1-pap-dvd-
edition-sandra-k-anderson-ba-lmt-abt-nctmb/
ebookfinal.com
Endodontics problem solving in clinical practice 1st

Edition T.R. Pitt Ford
https://ebookfinal.com/download/endodontics-problem-solving-in-
clinical-practice-1st-edition-t-r-pitt-ford/
ebookfinal.com
College practical chemistry Patel
https://ebookfinal.com/download/college-practical-chemistry-patel/
ebookfinal.com
Annual Reports on NMR Spectroscopy Volume 83 1st Edition

Webb
https://ebookfinal.com/download/annual-reports-on-nmr-spectroscopy-
volume-83-1st-edition-webb/
ebookfinal.com
Recent Exploration in Indian English Writings M. F. Patel
https://ebookfinal.com/download/recent-exploration-in-indian-english-
writings-m-f-patel/
ebookfinal.com
Cone Beam Computed Tomography in
Endodontics
Shanon Patel · Simon Harvey · Hagay Shemesh · Conor Durack

Shanon Patel · Simon Harvey · Hagay Shemesh · Conor Durack
Cone Beam Computed Tomography in
Endodontics
Contributors
Francesca Abella Sans DDS, PhD
Program Co-ordinator of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Barcelona, Spain
Bhavin Bhuva BDS, MFDS RCS, MClinDent, MRD RCS (Edin)
Consultant in Endodontics, Endodontic Postgraduate Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK and
Specialist practice, London, UK
Conor Durack BDS, MFD RCSI, MClinDent, MEndo RCS (Edin)
Specialist in Endodontics, Limerick, Ireland
Simon C Harvey BDS, MA (MedLaw), MFDS RCS (Edin)
Specialist Registrar in Dental and Maxillofacial Radiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Shalini Kanagasingam BDS, MClinDent, MFDS RCS (Eng), MRD RCS (Edin)
Head of Operative Dentistry, National University of Malaysia, Kaula Lumpur, Malaysia
Shanon Patel BDS, MSc, MClinDent, FDS RCS (Edin), MRD RCS (Edin), PhD
Consultant/Honorary Senior Lecturer in Endodontics, King’s College London Dental Institute, London, UK and Specialist
practice, London, UK
Navid Saberi BDS, MFDS RCS (Edin), MSc
Private practice (limited to Endodontics), Brighton, UK
Hagay Shemesh DMD, PhD
Associate Professor and Chair, Division of Endodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam,
The Netherlands
Mitsuhiro Tsukiboshi DDS, PhD
General Practitioner and Chairperson of Tsukiboshi Dental Clinic, Aichi, Japan and Clinical Professor, Tohoku University,
Graduate School of Dentistry, Japan
Cindy Verdegaal DMD
Postgraduate in Endodontics, Division of Endodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The
Netherlands
Eric Whaites MSc, BDS, FDS RCS (Edin), FDS RCS (Eng), FRCR, DDR RCR
Senior Lecturer/Honorary Consultant in Dental and Maxillofacial Radiology, King’s College London Dental Institute, London,
UK
Berlin, Chicago, Tokyo, Barcelona, Bucharest, Istanbul, London, Milan, Moscow, New Delhi, Paris, Beijing, Prague, Riyadh, São
Paulo, Seoul, Singapore, Warsaw and Zagreb
A CIP record for this book is available from the British Library.
ISBN:
978-3-86867-333-3 (ebook)
978-1-85097-291-4 (print)
Quintessence Publishing Co. Ltd,

Grafton Road, New Malden, Surrey KT3 3AB,
United Kingdom
www.quintpub.co.uk
Copyright © 2016
Quintessence Publishing Co. Ltd
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Editing: Quintessence Publishing Co. Ltd, London, UK
Layout and Production: Quintessenz Verlags-GmbH, Berlin, Germany
Index: Indexing Specialists (UK) Ltd
Printed and bound in Germany
Acknowledgements
To our families
The editors would like to thank the following:
Francesco Mannocci, per i tuoi saggi consigli;

Andrew Dawood for being ahead of the game, and introducing me to the ‘third dimension’ in
2006;
The endodontic staff and postgraduate team at King’s College London Dental Institute.
Shanon Patel
Jackie Brown, Marta Varela, Eric Whaites and Georgina Harvey for their invaluable
assistance.
Simon Harvey
JA Baart, Department of Maxillofacial Surgery, and JA Castelijns, Head and Neck Radiology,
of the VU Medical Centre, Amsterdam, Netherlands.
Hagay Shemesh
Eilis Lynch at Ennis Periodontology and Implant Clinic, and my colleagues at Riverpoint
Specialist Dental Clinic, Limerick.
Conor Durack
Foreword
The primary objectives of Restorative Dentistry are to relieve pain, prevent tooth loss and
restore lost oral and dental tissues to meet the aesthetic, psychological and functional needs of
patients. These key objectives often require the coordination of multi-professional teams,
which in the context of this book include Endodontists.
The use of cone beam computed tomography (CBCT) in dentistry, and specifically
endodontics, is controversial, and although several position statements and guidance
documents have been published in recent years, there remains a lack of knowledge and a
degree of misunderstanding about the benefits and risks associated with this diagnostic tool.
Without doubt, there has been a need for a comprehensive and authoritative textbook that
covers all the elements of this subject in relation to diseases of the pulp and periapical region.
Thus, this new book on CBCT and endodontics is timely, and provides a rich resource for
specialists in Endodontology and Maxillofacial Radiology. It is also an excellent reference
book for general dentists, trainees on clinical training pathways, as well as students on
specialist postgraduate programmes and undergraduates using CBCT.
The book is user-friendly and is divided into two sections. The initial chapters (1–4) cover
the important and essential aspects of radiology in relation to CBCT, which is an area that is
often underemphasised and misunderstood. The remaining chapters (5–11) are dedicated to the
various applications of CBCT in endodontics. An essential focus running throughout the book
is the understanding that, as CBCT is associated with a higher effective patient radiation dose,
the ALARA principles are paramount.
Each chapter is written by subject specialists who have a wealth of research and clinical
experience. The book is extensively illustrated with conventional radiographic and CBCT
images, all with comprehensive legends.
CBCT is a relatively modern imaging method that provides a substantial amount of
clinically relevant information. The book provides an excellent review of the subject,
emphasises case selection and is supported by key references to provide an evidence-based
approach and a framework for the use of CBCT in endodontics.
Professor Paul MH Dummer BDS, MScD, PhD, DDSc,

FDS RCS (Edin), FHEA
Professor of Restorative Dentistry,

Dean of Education and Students, Cardiff University
Secretary of the European Society of Endodontology
Cardiff
October 2015
Preface
Endodontics relies on radiographic imaging for diagnosis, treatment planning and the
assessment of healing. However, conventional radiographic imaging has several well-
documented limitations, which can result in an impaired diagnostic yield, and potentially
influence treatment planning.
In recent years, cone beam computed tomography (CBCT) has become much more widely
available and utilised in all aspects of dentistry, including endodontics. CBCT overcomes
many of the limitations of conventional radiography and has been shown to be essential for the
diagnosis and management of complex endodontic problems.
The editors of Cone Beam Computed Tomography in Endodontics are all experienced users
of CBCT. In their clinical practice and academic/teaching roles, they recognised the need for a
guide to illustrate the applications of CBCT in endodontics using the latest evidence and
principles.
The aim of the book is two-fold; firstly, to give the reader a thorough account of the
radiological aspects of CBCT; and secondly, to comprehensively illustrate the applications of
CBCT in endodontics. The book emphasises the fact that, inherent in the responsible use of
CBCT is the understanding that, as CBCT is associated with a higher effective patient
radiation dose than conventional radiographic imaging, the prescription of CBCT must be
justified, and the associated radiation exposure be kept as low as reasonably achievable.
This book gives the reader a sound foundation on small field of view, high resolution CBCT
and its applications in endodontics. However, one cannot overemphasise the fact that dental
radiology is continuously evolving. As such, it is essential that CBCT users keep abreast of
developments in dental radiology and maintain a contemporaneous core knowledge of both
dental radiology and of CBCT, specifically.
Shanon Patel
Simon C Harvey
Hagay Shemesh
Conor Durack
Contents
Chapter 1 The Limitations of Conventional Radiography and Adjunct

Imaging Techniques
Introduction
Limitations of conventional radiographic imaging
Superimposition of three-dimensional anatomy
Geometric distortion
Anatomical noise
Follow-up radiographs
Advanced radiographic techniques for endodontic diagnosis
Magnetic resonance imaging
Ultrasound
Tuned aperture computed tomography
Computed tomography
Cone beam computed tomography
Conclusions
Acknowledgement
References
Chapter 2 Radiation Physics
Introduction
The electromagnetic wave
Individual photons or continuous waves?
X-ray production
Bremsstrahlung
Characteristic radiation
Heat
Spectrum profile
Filtering
Altering the mA or kV
Summary
Interaction with matter
Absorbed X-rays
Scattered X-rays
Transmitted X-rays
Further reading
Chapter 3 Cone Beam Computed Tomography
The differences and similarities between multidetector computed tomography and cone beam
computed tomography
Multidetector computed tomography
CBCT
Detector types
Image intensifier
Indirect digital flat panels
Direct digital flat panels
Comparing the three detector types
Detective quantum efficiency
Image reconstruction methods
Filtered back projection
Problems with filtered back projection and iteration
Image quality
Contrast resolution
Spatial resolution
Testing contrast and spatial resolution
Noise
Unsharpness
Ideal machine characteristics
Further reading
Chapter 4 Using CBCT: Dose, Risks and Artefacts
Introduction
Dose and risk
Ionising biological tissue
Stochastic risk
Measuring dose
UK background dose
Age and risk
Estimating risk
Dose-reducing measures
Justification
Ensure patient is set up correctly
Raise kV and reduce mA
Dose-reduction feature
Larger voxels
Low mA
Correct filtering
mA modulation
Physical collimation
180-degree views
Pulsed beam
Average dose for CBCT scanners
Artefacts in CBCT
Extinction artefacts
Beam-hardening artefacts
Partial volume effect
Aliasing artefacts
Ring artefacts
Motion artefacts
Noise
Summary of artefacts
Viewing and storing images
PACS
DICOM
Viewing monitor
Lighting conditions
Storage of images
Training requirements
CBCT-specific regulations
Assessment of images
Further reading
Chapter 5 Dentoalveolar Anatomy
Introduction
The anatomy of the maxilla and palatine bone
The anatomy of the nose and nasal cavity
The anatomy of the maxillary sinus
The anatomy of the alveolar bone
http://dentalebooks.com
The anatomy of the maxillary teeth
The anatomy of the mandible
The anatomy of the mandibular canal
The anatomy of the mental foramen
The mandibular alveolar bone
Conclusions
References
Chapter 6 Assessment of Root Canal Anatomy
Introduction
Complex anatomy
Incisor and canine teeth
Premolar teeth
Molar teeth
Anomalous tooth forms
Dens invaginatus
Taurodontism
Fused teeth
Pulp chamber parameters
Root length and curvature
Conclusion
References
Chapter 7 Apical Periodontitis
Introduction
Limitations of conventional periapical radiography
Detection of apical periodontitis
Assessment of the outcome of endodontic treatment
Radiographic appearance of apical periodontitis
Conventional radiography
Conclusion
References
Chapter 8 Non-surgical and Surgical Re-treatment
Introduction
Non-surgical endodontic re-treatment
Presence of a periapical lesion
Quality of existing root canal treatment
Missed root canals and anatomical features
Surgical endodontic re-treatment
Conclusion
References
Chapter 9 Traumatic Dental Injuries
Introduction
Radiographic assessment of TDI
Background
Radiographic assessment of specific TDI
Radiographic follow-up of TDI
Conclusion
References
Chapter 10 Root Resorption
Introduction
External root resorption
Internal root resorption
External root resorption
External surface resorption
External inflammatory resorption
External replacement resorption
External cervical resorption
Internal root resorption
Conclusion
References
Chapter 11 Vertical Root Fractures
Introduction
Conventional radiography
Ex vivo studies
In vivo studies
Conclusion
References
Index
Chapter 1
The Limitations of Conventional
Radiography and Adjunct Imaging
Techniques
Shanon Patel, Bhavin Bhuva, Eric Whaites
Introduction
Radiographic assessment is essential in every aspect of endodontics, from diagnosis to the
management and assessment of treatment outcome (Forsberg, 1987a, b; Patel et al, 2015).
Intraoral periapical radiography has historically been accepted as the most appropriate
imaging system in endodontics. However, conventional periapical images yield limited
information, which can potentially have an impact on diagnosis and treatment planning.
The purpose of this chapter is to describe the limitations of conventional periapical
radiography, and to discuss the relative advantages and disadvantages of alternative imaging
techniques.
Limitations of conventional radiographic imaging

Superimposition of three-dimensional anatomy
Conventional radiography results in three-dimensional (3D) structures being superimposed and
displayed as a two-dimensional (2D) image (Nance et al, 2000; Cohenca et al, 2007). The
resulting image allows complex dentoalveolar anatomy to be visualised only in the mesiodistal
(clinical) plane, and provides limited information of the dental anatomy in the buccolingual
(non-clinical) plane.
Radiographic 2D images prevent accurate assessment of the spatial relationship of the roots,
and associated periapical lesions, to the surrounding anatomy (Cotti and Campisi, 2004). In
addition, the location, nature, and shape of variations within the root under investigation (e.g.
root resorption) may be difficult to assess (Patel et al, 2007; Whaites and Drage, 2013a).
Diagnostic information in the missing ‘third dimension’ is of relevance when planning for
endodontic surgery (Velvart et al, 2001; Bornstein et al, 2011). Useful information may include
the position and angulation of the root/s in relation to the cortical plate, the thickness of the
cortical plate itself, and the relationship of the root/s to adjacent anatomical structures, such as
the inferior alveolar nerve, mental foramen or maxillary sinus (Lofthag-Hansen et al, 2007).
Additional parallax radiographic images, taken by changing the horizontal and/or vertical
angulation of the X-ray beam in relation to the area under examination (Figs 1-1 and 1-2), may
be used to enhance assessment of the spatial relationships of the imaged anatomical structures
(European Society of Endodontology, 2006; Davies et al, 2015). However, these additional
images will still only provide limited information (Soğur et al, 2012; Kanagasingam et al,
2015).
Fig 1-1 Horizontal parallax. The right radiograph has a 10-degree shift to aid visualisation of the two separate canals, which
allows the quality of the root canal fillings to be assessed more accurately in the mandibular central incisors.
Fig 1-2 Vertical parallax. A vertical beam shift (change in inclination) has caused the periapical lesions (red arrows)
associated with all three roots of this maxillary right first molar to disappear with the change of angulation in the right
radiograph. Note that the defective distal margin on the left radiograph (yellow arrow) is also no longer visible on the right
radiograph.
Geometric distortion
Intraoral periapical radiographic images should ideally be taken with a paralleling technique.
The use of a biteblock to ensure the tooth and image receptor are parallel with one another, as
well as the use of a beam aiming device to ensure the X-ray beam meets the tooth and image
receptor at right angles, has been proven effective at creating a geometrically accurate image
(Forsberg, 1987a, b, c).
An accurate image is obtained when the image receptor (X-ray film or digital sensor) is
parallel to the long axis of the tooth, and the X-ray beam is perpendicular to both the image
receptor and the tooth undergoing examination (Fig 1-3). This may be readily achievable in
certain regions of the oral cavity, but may not be possible in some patients with e.g. small
mouths or pronounced gag reflexes, and/or where the image receptor is poorly tolerated.
Anatomical limitations, such as a shallow palatal vault, prevent the ideal positioning of the
intraoral image receptor, causing incorrect long-axis orientation—which in turn results in
geometric distortion (poor projection geometry) of the radiographic image (Figs 1-3 and 1-4).
The ideal positioning of solid-state digital sensors may be even more challenging due to their
size and rigidity, compared with conventional radiographic films and phosphor plate digital
sensors (Patel et al, 2009a; Whaites and Drage, 2013a).
Ideal positioning of the image receptor may be possible when, firstly, the roots being imaged
are relatively straight and, secondly, when there is sufficient space to position the image
receptor correctly. If these objectives are not achieved (Fig 1-5), there will be a degree of
geometric distortion and magnification. This may be particularly relevant in the posterior
maxilla (Lofthag-Hansen et al, 2007). Over- or underangulated radiographs may reduce or
increase the ‘apparent’ radiographic root length of the tooth under investigation (White and
Pharaoh, 2014), and increase or decrease the size, or even result in the disappearance, of
periapical lesions (Bender and Seltzer, 1961a, b; Huumonen and Ørstavik, 2002). A minimum
5% magnification of the imaged structures will occur, even when a ‘textbook’ paralleling
technique has been employed (Vande Voorde and Bjorndahl, 1969).
Anatomical noise
Anatomical features within or superimposed over the roots being examined may obscure the
area of interest, thereby preventing a thorough assessment of the imaged region (Gröndahl and
Huumonen, 2004). These anatomical structures vary in radiodensity, and may be radiopaque or
radiolucent. This phenomenon is sometimes referred to as ‘anatomical noise’ (Fig 1-6). The
more complex the anatomical noise, the greater the reduction in contrast within the area of
interest. The resulting radiographic image may be more difficult to interpret.
Fig 1-3 Geometric distortion. Although it may be possible to position the image sensor holder (and image sensor) parallel
with the long axis of the crown and mid-third of the root, it is not possible to obtain a parallel relationship of the long axis of
the entire tooth and root with the image sensor. The sagittal reconstructed CBCT image shows a parallel (and accurate)
relationship of the mid-third root (green line) and the image sensor, and perpendicular X-ray beam (blue arrow). However,
the apical third (red line) is not parallel to the image sensor or perpendicular to the X-ray beam, resulting in geometric
distortion of the apical third of the root canal.
Fig 1-4 Geometric distortion. A distolingual canal (yellow arrow) can be seen on the intraoral radiograph (left). A coronal
reconstructed CBCT image (right) clearly demonstrates how the distolingual root cannot be accurately assessed in the
radiographic image. Neither the coronal (red line) nor apical (green line) halves of this root canal are parallel to the image
sensor (yellow arrow), or perpendicular to the X-ray beam (blue arrow). This results in significant geometric distortion in this
region of the image.
Fig 1-5 Geometric distortion. It may not be possible to position the image sensor in the ideal position, resulting in distortion of
the resulting image. When imaging these maxillary left premolar teeth, the anatomical constraints of a shallow palate have
prevented a paralleled image from being obtained.
Fig 1-6 Anatomical noise. (a) A periapical radiolucency is clearly seen, and is associated with the maxillary left incisor
(yellow arrow). (b) A second radiograph taken at a 10-degree horizontal shift reveals an additional periapical radiolucency
(red arrow) associated with the maxillary left incisor. This ‘new’ radiolucency is the incisive foramen, which in this case
creates radiolucent anatomical noise mimicking a periapical lesion.
Fig 1-7 Anatomical noise. The superimposition of anatomical structures prevents complete and accurate assessment of the
imaged teeth. As demonstrated in these parallax periapical radiographs, the maxillary sinus and zygomatic buttress may often
create anatomical noise, which prevents visualisation of the periapical regions of the maxillary premolar and molar teeth.
Brynolf (1967, 1970a, b) demonstrated that superimposition of the incisive canal over the
apices of the maxillary central incisors may complicate radiographic interpretation, i.e. the
incisive foramen (anatomical noise) mimicked periapical lesions in healthy teeth.
Several studies have shown that periapical lesions confined to the cancellous bone may not
be detected with conventional radiographic imaging (Bender and Seltzer, 1961a, b). It has been
suggested that periapical lesions may be successfully detected when confined to cancellous
bone, provided the cortical bone is thin and the anatomical noise minimal. Such lesions may go
undetected beneath a thicker cortex. Anatomical noise also accounts for some underestimation
of periapical lesion size in radiographic images (Shoha et al, 1974; Marmary et al, 1999;
Scarfe et al, 1999).
The maxillary molar region is a complex anatomical region with a number of closely related
structures, which include the maxillary sinus and zygomatic buttress (Fig 1-7).
Anatomical noise is dependent on several factors that may include: overlying anatomy; the
thickness of the cancellous bone and cortical plate; and the relationship of the root apices to
the cortical plate. Brynolf (1967) compared the radiographic and histological appearance of
292 maxillary incisor teeth to assess whether there was a relationship between the
radiographic and histological features of the periapical lesions. Overall, there was a high
correlation between radiographic and histological findings; this conclusion may have been
related to the lack of anatomical noise in the specific area being assessed. The root apices of
maxillary incisors lie very close to the adjacent cortical plate, and therefore erosion of this
cortex may often occur soon after periapical inflammation ensues. In other areas of the jaws
with increased anatomical noise, e.g. the posterior mandible with its thicker cortical plate, the
correlation between histological findings and radiographic appearance may be less
interrelated (Patel et al, 2009b).
Follow-up radiographs
Sequential radiographic images, taken over a period of time, are required when determining
endodontic treatment outcomes (European Society of Endodontology, 2006). An accurate
comparison can only be made when these images have been standardised with respect to
radiation geometry, density, and contrast. Poorly standardised radiographs may lead to
misinterpretation of the disease status (Bender et al, 1961a, b).
The use of customised bite blocks may be helpful in obtaining standardised images, but even
then, no two images will be identical.
Advanced radiographic techniques for endodontic diagnosis

In order to overcome the limitations of conventional intraoral radiographs, a number of
alternative imaging techniques to complement periapical radiography have been suggested.
These include:
magnetic resonance imaging
ultrasound
tuned aperture computed tomography
computed tomography
cone beam computed tomography.
Magnetic resonance imaging

Magnetic resonance imaging (MRI) is a specialised technique that utilises hydrogen atoms (one
proton and one electron) and a magnetic field to produce an a magnetic resonance (MR) image.
This imaging technique does not use ionising radiation.
For image acquisition, the patient is positioned within an MRI scanner that creates a strong
magnetic field around the area being imaged (Fig 1-8a). Tissues that are composed of water
contain protons (hydrogen atoms). Energy from the oscillating magnetic field is temporarily
applied to the patient at the appropriate resonant frequency. This aligns the protons contained
along the long axis of the magnetic field and the patient’s body. A pulsed beam of radio waves,
with a similar frequency to the patient’s spinning hydrogen atoms, is then transmitted
perpendicular to the magnetic field. This misaligns the hydrogen protons, resulting in an
alteration of their axis of rotation from a longitudinal to a transverse plane (Fig 1-8b). The
atoms behave like several mini bar magnets, spinning synchronously with each other. This
generates a radio signal (resonance) that is detected by the receiver within the scanner (Fig 1-
8c). Similar radio signals are detected as the hydrogen protons relax and return to their
original (longitudinal) direction. A computer processes the receiver information, and an image
is thereby produced (White and Pharaoh, 2014; Whaites and Drage, 2013b).
MRI has been used for the investigation of soft tissue lesions in salivary glands, the
investigation of the temporomandibular joint, for tumour staging (Goto et al, 2007), and for the
treatment planning of dental implants (Imamura et al, 2004; Monsour and Dhudia, 2008).
The MRI technique has been used to assess a cohort of patients with periapical disease.
With MRI, it was possible to differentiate the roots of multirooted teeth, and smaller branches
of the neurovascular bundle could be clearly identified entering apical foramina. The presence
and nature of periapical lesions could also be determined, as could the remodelling of the
cortical bone. An important advantage of MRI is that, unlike computed tomography (CT)
imaging, it is not affected by artefacts caused by metallic restorations (Eggars et al, 2005).
There are several limitations to MRI, including poor resolution when compared with
conventional radiographic images. The scanning times involved with the MRI technique are
lengthy, and the cost and maintenance of the imaging hardware results in the scanners seldom
being found anywhere but in dedicated radiology units. The dental hard tissues (e.g. enamel
and dentine) cannot be differentiated from one another, or from metallic objects, as they all
appear radiolucent. This currently limits the endodontic applications of MRI. Finally, MRI
scanners need highly trained radiographers to take the image, and radiologists to interpret the
resulting scan.
To make the MRI technique more applicable to the oral cavity, researchers have developed
a technique that utilises an intraoral loop coil placed in the occlusal position. This technique
has been shown to detect caries lesions in vivo (Tymofiyeva et al, 2009; Idiyatullin et al,
2011), and to differentiate between sound and carious dentine due to the porosity of the latter,
which in turn has a higher water content (Tymofiyeva et al, 2009). Coil MRI has also been
used to determine the distance from caries lesions to the pulp. While the potential applications
of coil MRI show promise, problems are acknowledged due to patient movement and the effect
of certain dental materials on image quality. However, it would seem that the MRI technique is
less sensitive to dental materials than other techniques, such as CT imaging (Eggars et al,
2005).
Fig 1-8 (a) The magnetic resonance imaging (MRI) technique involves the formation of a magnetic field around the area
being imaged. The protons within the magnetic field and body then become aligned along the long axis. (b) A pulsed beam of
radio waves is transmitted perpendicular to the long axis of the magnetic field, causing the protons to be disrupted, and
altering their axis of rotation. (c) The disrupted protons spin synchronously with one another, producing a faint radio signal,
which in turn is sent back to a receiver. A computer processes the resulting signal and the image is produced.
One of the limitations of the conventional MRI technique is that the densely calcified dental
tissues cause deterioration of the MRI signal before digitisation is achieved, which results in
weakened or absent MRI signals. Thus, the majority of MRI studies in relation to dentistry
have been on the dental soft tissues, including the pulp and periodontal ligament.
In addition to the limitations previously described, coil MRI lacks the ease of use of other
imaging techniques. Furthermore, the costs involved with coil MRI are significant. As a result,
access to suitable coil MRI scanning equipment is limited.
Fig 1-9 Ultrasound. An extraoral transducer probe emits and detects the ultrasound (US) signal. The US signal is created
using the piezoelectric effect.
Fig 1-10 Ultrasound (US). (a) This patient presented with a large, fluctuant swelling palatal to the maxillary right anterior
teeth. (b) Periapical radiographs demonstrated a large radiolucency encompassing the apices of the root-treated maxillary
right central incisor, lateral incisor and canine teeth. Two-dimensional radiographs (b to d) fail to provide information on the
depth of the lesion and the location of resorption of the respective buccal and palatal cortical plates. (e) A US scan of the
area was conducted by placing a probe extraorally over the region of interest. The resultant scan images the relative
hyperechoic and hypoechoic regions, demonstrating the buccolingual extent of the periapical lesion, as well as the locations
where the cortical plates have been resorbed.
Ultrasound
The ultrasound (US) technique is based on the reflection (echoes) of US waves at the interface
between tissues that have different acoustic properties (Gundappa et al, 2006). Ultrasonic
waves are created using the piezoelectric effect via a transducer (probe). The beam of US
energy is emitted and reflected back to the same probe (i.e. the probe acts as both emitter and
detector). A transducer detects the echoes and converts them into an electrical signal (Fig 1-9).
The resulting real-time image is composed of black, white, and shades of grey. As the probe is
traversed across the area of interest, new images are generated in real time. The intensity or
strength of the detected echoes is dependent on the difference between the acoustic impedance
of two adjacent tissues. The greater the difference between the tissues, the greater the
distinction in the reflected US energy, resulting in higher echo intensity. Tissue interfaces that
generate high echo intensity are described as hyperechoic (e.g. bone and teeth). Anechoic
tissues (e.g. fluid-filled cysts) are those that do not reflect US energy (Fig 1-10). Images
consisting of varying degrees of hyperechoic and anechoic usually have a heterogeneous
profile. The Doppler effect (the change of sound frequency reflected from a moving source)
can be used to assess arterial and venous blood flow (Whaites and Drage, 2013b).
Fig 1-11 Tuned aperture computed tomography (TACT). With this technique, 8 to 10 digital radiographic images are taken
at different defined projection geometries. The images are reconstructed to provide 3D data, which may be viewed slice by
slice.
US has been used to diagnose the full nature of periapical lesions (Cotti et al, 2003). In this
study, 11 periapical lesions of endodontic origin were assessed with US imaging. Provisional
diagnoses were made according to the echo images (hyperechoic and hypoechoic). The
evidence of vascularity within the lesions was determined using the colour laser Doppler
effect. The provisional diagnoses (seven cysts, four granulomas) were successfully confirmed
by histology in all 11 cases. A similar study also concluded that US was a reliable diagnostic
technique for determining the pathological nature (granulomas versus cysts) of periapical
lesions (Gundappa et al, 2006). However, in both of these studies the apical biopsies were not
removed together with the root apices, therefore making it impossible to confirm whether the
assessed lesions were true or pocket cysts. Furthermore, the lesions were not serially
sectioned, making accurate histological diagnosis unreliable (Nair et al, 1996). Therefore, the
ability of US to assess the true nature of periapical lesions is questionable.
Doppler flowmetry has also been used to assess the outcome of orthograde root canal
treatment in maxillary anterior teeth (Maity et al, 2011). It was demonstrated that healing could
be established earlier with the Doppler technique when compared with conventional
radiographs. Evidence of healing was apparent in the majority of cases after just 6 weeks when
assessed with Doppler flowmetry.
US energy is unable to penetrate bone effectively and is therefore only useful when
assessing periapical lesions with little or no overlying cortical bone. While US may be used
with relative ease in the anterior region of the mouth, the positioning of the probe is more
difficult against the buccal mucosa of posterior teeth. In addition, the interpretation of US
images is limited to radiologists who have received relevant training.
Tuned aperture computed tomography

Tuned aperture computed tomography (TACT) is based on the concept of tomosynthesis
(Webber and Messura, 1999). A series of 8 to 10 radiographic images are exposed at different
projection geometries using a programmable imaging unit with specialised software to
reconstruct a 3D data set, which can then be viewed slice by slice (Fig 1-11).
The advantage of TACT over conventional radiographic imaging is that there is less
superimposition of anatomical noise over the area of interest (Tyndall et al, 1997). The overall
radiation dose of TACT is no greater than one to two times that of conventional periapical X-
ray exposure, as the total dose is divided among the series of exposures (Nair et al, 1998;
Nance et al, 2000). Additional advantages claimed for this technique include the absence of
artefacts resulting from radiation interaction with metallic restorations (see later section on
CT). The resolution is reported to be comparable to 2D radiographs (Nair and Nair, 2007).
TACT appears to have potential benefits that may make it useful in the future. For the time
being, however, the technique for the imaging of dentoalveolar anatomy should be considered
as a research tool.
Fig 1-12 Computed tomography (CT). (a) A large periapical radiolucency associated with the maxillary left lateral incisor
and canine teeth is revealed following periapical radiographic examination. (b) The gantry of the CT scanner contains the X-
ray source and the imaging detectors. The patient is advanced through a circular aperture in the centre of the scanner. The
patient is thereby scanned ‘slice by slice’ while being advanced through the scanner. (c) The reconstructed slices can then
be observed individually in the imaged plane. In this case, the width and depth of the periapical radiolucency can be assessed
at each of the axial sections (red arrows).
Computed tomography
Computed tomography (CT) is an imaging technique that produces 3D radiographic images
using a series of 2D sectional X-ray images. Essentially, CT scanners consist of a gantry that
contains the rotating X-ray tube head and reciprocal detectors. In the centre of the gantry is a
circular aperture through which the patient is advanced. The tube head and reciprocal detectors
within the gantry either rotate synchronously around the patient, or the detectors take the form
of a continuous ring around the patient and only the X-ray source moves within the detector
ring (Fig 1-12a and b). The data from the detectors produces an attenuation profile of the
particular slice of the body being examined. The patient is then moved slightly further into the
gantry for the next slice of data to be acquired. The process is repeated until the area of interest
has been fully scanned.
Fig 1-13 Multislice computed tomography (MSCT). To overcome the limitations of CT, the CT beam width is widened, and
detectors are arranged in multiple rows, enabling the entire fan beam to be captured at any one time.
Early generation CT scanners acquired ‘data’ in the axial plane by scanning the patient
‘slice by slice’, using a narrow collimated fan-shaped X-ray beam passing through the patient
to a single array of reciprocal detectors. The detectors measured the intensity of X-rays
emerging from the patient.
Over the past three decades, there have been considerable advances in CT technology (Yu et
al, 2009; Runge et al, 2015). To overcome the problems of conventional (single slice) medical
CT imaging, which results in relatively poor image quality, the technique of multislice
computed tomography (MSCT) was developed. Here, the CT beam is widened in the z-
direction (beam width), and instead of a single detector, multiple detectors are arranged in
parallel rows, so that a number of slices can be obtained by capturing the entire fan beam at
any one time (Fig 1-13). This reduces the number of rotations of the X-ray tube and therefore
the radiation dose. The number of detectors on MSCT scanners has increased, facilitating a
greater number of simultaneously acquired images.
A number of researchers have evaluated MSCT and compared it to cone beam computed
tomography (CBCT). One autopsy study demonstrated that the quality of small-volume CBCT
scans might be better or at least equal to MSCT in assessing delicate anatomical structures,
such as the periodontal ligament and bone trabeculae.
In addition to providing multiplanar 3D images, CT has several other advantages over
conventional radiography. These include the elimination of anatomical noise and high contrast
resolution, allowing differentiation of tissues with less than 1% physical density difference,
compared with the 10% variation in physical difference that is required with conventional
radiography (White and Pharaoh, 2014).
A number of studies have used CT imaging to manage endodontic problems (Velvart et al,
2001; Huumonen et al, 2006). These were able to obtain additional information on the root
canal anatomy when compared with plain film radiographs (Tachibana and Matsumoto, 1990).
Valuable information on the relationship of the root apices with important anatomical
structures, such as the maxillary sinus, was obtained using reconstructed axial slices and 3D
reconstruction of the CT data. The information derived from CT scans has been compared with
that obtained from periapical radiographs when planning periapical surgery (Velvart et al,
2001). Of the 50 mandibular molar teeth assessed, CT imaging detected the presence of a
periapical lesion and the location of the inferior alveolar nerve in every case, compared with
only 78% and 39%, respectively, with periapical radiographs. Furthermore, the buccolingual
thickness of the cortical and cancellous bone, as well as the position and angulation of the root
within the mandible, could only be assessed by CT. It was concluded that ‘CT should be
considered before the surgical treatment of mandibular premolars and molars when the
mandibular canal is not detectable or appears in close proximity to the periapical lesion or
root with conventional radiographic techniques’.
Fig 1-14 Small volume CBCT imaging. The cone-shaped X-ray beam synchronously rotates around the patient, together
with the imaging detector.
The diagnostic value of CT and parallax periapical radiographs has been compared when
assessing maxillary molar teeth for endodontic re-treatment (Huumonen et al, 2006). Periapical
lesions were more reliably detected with CT when compared with periapical radiographs. In
addition, the distance between the palatal and buccal cortical plates and the adjacent root
apices could only be determined with CT. The authors of this study concluded that ‘the
information obtained from CT was essential for decision making in surgical re-treatment’.
However, one should bear in mind that a high radiation dose is required to achieve an adequate
resolution for assessing root canal anatomy.
The assessment of the ‘third dimension’ with CT imaging also allows the number of roots
and root canals to be determined, as well as their anatomy in all three planes. The additional
information may be extremely useful when diagnosing and managing persistent endodontic
disease, which may remain undetected with conventional radiography. For example, CT has
been used to detect the high incidence of unfilled second mesiobuccal canals in root-treated
maxillary molars (Huumonen et al, 2006). Correspondingly, the majority of roots with unfilled
canals had associated periapical lesions.
The uptake of CT in endodontics has been limited. This is primarily due to the high effective
dose and relatively low resolution of the imaging technique. Other disadvantages of CT
include the high costs of the scans, scatter due to metallic objects, poor resolution compared
with conventional radiographs, and the limited availability of the scanners (e.g. hospital
radiography units). Access for dentists in practice is therefore limited. CT technology has now
been superseded by CBCT technology in the management of endodontic problems.

Cone beam computed tomography (CBCT)—also known as digital volumetric imaging—is an
extraoral imaging technique that was developed in the late 1990s to produce 3D scans of the
maxillofacial skeleton at a considerably lower radiation dose than CT (Mozzo et al, 1998;
Arai et al, 1999). CBCT differs from CT imaging in that the entire 3D volume of data is
acquired in the course of a single sweep by the scanner, using a simple, direct relationship
between sensor and source, which rotate synchronously around the patient’s head (Fig 1-14).
The X-ray source and the detector rotate between 180 to 360 degrees around the patient.
Unlike CT scans, most CBCT scans are taken with the patient sitting or standing up. The X-ray
beam is cone-shaped (hence the name of the technique), capturing a cylindrical or spherical
volume of data, described as the field of view (FOV). The FOV varies between different
CBCT scanners (Pauwels et al, 2012). Each reconstructed image is comprised of a number of
volumetric pixels, which are described as voxels. Voxel size typically ranges from between
0.08 to 0.125 mm3.
Small FOV CBCT scanners usually have a lower effective dose than CT scanners. This is
due, in part, to rapid scan times, a very low radiation dose for each X-ray image, and
sophisticated image receptor sensors. The pulsed X-ray beam results in up to 950 ‘projection
images’ or basis exposures being taken, as the X-ray source and detector rotate around the
patient. CBCT scanners are simple to use and take up about the same amount of space as
panoramic radiographic machines, making them suitable for dental practices. Decreasing the
size of the FOV, increasing the voxel size, and/or reducing the number of projection images
taken as the X-ray source rotates around the patient may further reduce the radiation dose.
Sectional images or ‘tomographic slices’, as thin as 1 voxel thick, may be displayed in a
number of ways. Typically, images are displayed in the three orthogonal planes—axial, sagittal
and coronal—simultaneously. Coronal and axial views of the tooth are readily produced,
allowing the clinician to gain a truly 3D view of the entire tooth and its surrounding anatomy.
Surface rendering is also possible to produce 3D images.
The image quality of CBCT scans is superior to that of helical CT scans for assessing dental
hard tissues. One study compared the image quality of an experimental CBCT scanner to a
MSCT scanner and concluded that CBCT had a higher resolution for detecting small, high-
contrast (i.e. hard tissue) structures such as ‘nerve canals’ carrying neurovascular bundles.
Hirsch et al (2003) reached a similar conclusion when they compared limited CBCT to MSCT.
However, the lower exposure settings of CBCT scans result in poor soft tissue contrast
compared with conventional CT scans.
CBCT is undoubtedly a major breakthrough in dental imaging. For the first time, the
clinician is able to use a patient-friendly imaging system to easily view areas of interest in any
plane, rather than being restricted to the superimposed 2D images available with conventional
radiography.
The radiographic aspects and specific applications of CBCT in endodontics will be
described in the subsequent chapters.
Conclusions
Images acquired using conventional intraoral radiographic techniques reveal information in
two dimensions only (height and width). Valuable and relevant information in the third
dimension (depth) is limited.
Due to the inherent problems of positioning intraoral image receptors in the correct position
in relation to the anatomical area of interest, it may not be possible to obtain an accurate,
undistorted view of the area of interest.
The detection and assessment of the true nature of endodontic lesions and other relevant
features may be impaired by adjacent anatomical noise. The effect of this anatomical noise
is unique for each patient and is dependent on the degree of bone demineralisation, size of
the endodontic lesion, and physical nature of the anatomical noise (i.e. its thickness, shape,
and the density of the overlying anatomy).
Serial radiographs taken with the paralleling technique are not consistently reproducible.
This may result in misinterpretation of the healing process or failure of the endodontic
treatment.
Acknowledgement
This chapter has been adapted from: Patel S, Dawood A, Whaites E, Pitt Ford T. New
dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems.
Int Endod J 2009a;42:447–462.
References
Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed tomographic apparatus for dental
use. Dentomaxillofac Radiol 1999;28:245–248.
Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone: I. J Am Dent Assoc
1961a;62:152–160.
Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone: II. J Am Dent Assoc
1961b;62:708–716.
Bornstein MM, Lauber R, Sendi P, von Arx T. Comparison of periapical and limited cone-beam computed tomography in
mandibular molars for analysis of anatomical landmarks before apical surgery. J Endod 2011;37:151–157.
Brynolf I. A histological and roentenological study of the periapical region of human upper incisors. Odontologisk Revy 1967;18:
(Suppl 11).
Brynolf I. Roentgenolgic periapical diagnosis. IV. When is one roentgenogram not sufficient? Sven Tandlak Tidskr
1970a;63:415–423.
Brynolf I. Roentgenolgic periapical diagnosis. III. The more roentgenograms—the better the information? Sven Tandlak Tidskr
1970b;63:409–413.
Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Clinical indications for digital imaging in dento-alveolar trauma. Part 1:
traumatic injuries. Dent Traumatol 2007;23:95–104.
Cotti E, Campisi G, Ambu R, Dettori C. Ultrasound real-time imaging in the differential diagnosis of periapical lesions. Int Endod
J 2003;36:556–563.
Cotti E, Campisi G. Advanced radiographic techniques for the detection of lesions in bone. Endod Topics 2004;7:52–72.
Davies A, Mannocci F, Mitchell P, Andiappan M, Patel S. The detection of periapical pathoses in root filled teeth using single
and parallax periapical radiographs versus cone beam computed tomography – a clinical study. Int Endod J 2015;48:582–
592.
Eggars G, Ricker M, Kress J, Fiebach J, Dickhaus H, Hassfeld S. Artefacts in magnetic resonance imaging caused by dental
material. MAGMA 2005;18:103–111.
European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of
Endodontology. Int Endod J 2006;39:921–930.
Forsberg J. Radiographic reproduction of endodontic ‘working length’ comparing the paralleling and the bisecting-angle
techniques. Oral Surg Oral Med Oral Pathol 1987a;64:353–360.
Forsberg J. A comparison of the paralleling and bisecting-angle radiographic techniques in endodontics. Int Endod J
1987b;20:177–182.
Forsberg J. Estimation of the root filling length with paralleling and bisecting-angle radiographic techniques performed by
undergraduate students. Int Endod J 1987c;20:282–286.
Goto TK, Nishida S, Nakamura Y, et al. The accuracy of three-dimensional magnetic resonance 3D vibe images of the
mandible: an in vitro comparison of magnetic resonance imaging and computed tomography. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2007;103:550–559.
Gröndahl HG, Huumonen S. Radiographic manifestations of periapical inflammatory lesions. Endod Topics 2004;8:55–67.
Gundappa M, Ng SY, Whaites EJ. Comparison of ultrasound, digital and conventional radiography in differentiating periapical
lesions. Dentomaxillofac Radiol 2006;35:326–333.
Hirsch E, Graf HL, Hemprich A. Comparative investigation of image quality of three different X-ray procedures.
Dentomaxillofac Radiol 2003;32:201–211.
Huumonen S, Ørstavik D Radiological aspects of apical periodontitis. Endod Topics 2002;1:3–25.
Huumonen S, Kvist T, Gröndahl K, Molander A. Diagnostic value of computed tomography in re-treatment of root fillings in
maxillary teeth. Int Endod J 2006;39:827–833.
Idiyatullin D, Corum C, Moeller S, Prasad HS, Garwood M, Nixdorf DR. Dental magnetic resonance imaging: making the
invisible visible. J Endod 2011;37:745–752.
Imamura H, Sato H, Matsuura T, Ishikawa M, Zezé R. A comparative study of computed tomography and magentic resonance
imaging for the detection of mandibular canals and cross-sectional areas in diagnosis prior to dental implant treatment. Clin
Implant Dent Relat Res 2004;6:75–81.
Kanagasingam S, Mannocci F, Lim CX, Yong CP, Patel S. Accuracy of single versus multiple images of conventional and digital
periapical radiography in diagnosing periapical periodontitis using histopathological findings as a reference standard. Int
Endod J 2015 (in press).
Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl HG. Limited cone-beam CT and intraoral radiography for the diagnosis
of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:114–119.
Maity I, Kumari A, Shukla AK, Usha H, Naveen D. Monitoring of healing by ultrasound with color power doppler after root
canal treatment of maxillary teeth with periapical lesions. J Conserv Dent 2011;14:252–257.
Marmary Y, Koter T, Heling I. The effect of periapical rarefying ostetis on cortical and cancellous bone. A study comparing
conventional radiographs with computed tomography. Dentomaxillofac Radiol 1999;28:267–271.
Monsour PA, Dhudia R. Implant radiography and radiology. Aust Dent J 2008;53(suppl 1):S11–S25.
Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A new volumetric CT machine for dental imaging based on the cone-
beam technique: preliminary results. Eur Radiol 1998;8:1558–1564.
Nair MK, Nair UP. Digital and advanced imaging in endodontics: a review. J Endod 2007;33:1–6.
Nair PNR, Pajarola G, Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1996;81:93–102.
Nair MK, Tyndall DA, Ludlow JB, May K, Ye F. The effects of restorative material and location on the detection of simulated
recurrent caries. A comparison of dental film, direct digital radiography and tuned aperture computed tomography.
Dentomaxillofac Radiol 1998;27:80–84.
Nance R, Tyndall D, Levin LG, Trope M. Identification of root canals in molars by tuned-aperture computed tomography. Int
Endod J 2000;33:392–396.
Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of
endodontic problems. Int Endod J 2007;40:818–830.
Patel S, Dawood A, Whaites E, Pitt Ford T. New dimensions in endodontic imaging: part 1. Conventional and alternative
radiographic systems. Int Endod J 2009a;42:447–462.
Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam
computed tomography and intraoral radiography. Int Endod J 2009b;42:507–515.
Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in endodontics—a review. Int
Endod J 2015;48:3–15.
Pauwels R, Beinsbergera J, Collaert B, et al. Effective dose range for dental cone beam computed tomography scanners. Eur J
Radiol 2012;81:267–271.
Runge VM, Marquez H, Andreisek G, Valavanis A, Alkadhi H. Recent technological advances in computed tomography and the
clinical impact therein. Invest Radiol 2015;50:119–127.
Scarfe WC, Czerniejewski VJ, Farman AG, Avant SL, Molteni R. In vivo accuracy and reliability of color-coded image
enhancements for the assessment of periradicular lesion dimensions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1999;88:603–611.
Shoha RR, Dowson J, Richards AG. Radiographic interpretation of experimentally produced bony lesions. Oral Surg Oral Med
Oral Pathol 1974;38:294–303.
Soğur E, Gröndahl HG, Baksi BG, Mert A. Does a combination of two radiographs increase accuracy in detecting acid-induced
periapical lesions and does it approach the accuracy of cone beam computed tomography scanning? J Endod 2012;2:131–
136.
Tachibana H, Matsumoto K. Applicability of X-ray computerized tomography in endodontics. Endod Dent Traumatol 1990;6:16–
20.
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. MAGMA 2009;22:365–374.
Tyndall DA, Clifton TL, Webber RL, Ludlow JB, Horton RA. TACT imaging of primary caries. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1997;84:214–225.
Vande Voorde HE, Bjorndahl AM. Estimated endodontic “working length” with paralleling radiographs. Oral Surg Oral Med
Oral Pathol 1969;27:106–110.
Velvart P, Hecker H, Tillinger G. Detection of the apical lesion and the mandibular canal in conventional radiography and
computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:682–688.
Webber RL, Messura JK. An in vivo comparison of digital information obtained from tuned-aperture computed tomography and
conventional dental radiographic imaging modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:239–247.
Whaites E, Drage N. Periapical radiography. In: Essentials of Dental Radiology and Radiography, ed 5. London, UK: Churchill
Livingston Elsevier, 2013a.
Whaites E, Drage N. Alternative and specialized imaging modalities. In: Essentials of Dental Radiology and Radiography, ed 5.
London, UK: Churchill Livingston Elsevier, 2013b.
White S, Pharaoh M. Advanced imaging modalities. In: Oral Radiology: Principles and Interpretation, ed 7. St Louis, MO:
Mosby, 2014.
Yu L, Liu X, Leng S, et al. Radiation dose reduction in computed tomography: techniques and future perspective. Imaging Med
2009;1:65–84.
Chapter 2
Radiation Physics
Simon C Harvey
Introduction
The aim of this chapter is, firstly, to explain what X-ray radiation is and, secondly, to describe
the production and interaction of X-ray radiation.
The electromagnetic wave

The electromagnetic wave describes a wave of energy that has an electric field alternating
(between positive and negative) along one axis. At right angles to this, a magnetic field
alternates between north and south (Fig 2-1). The two are often drawn as one wave to make
their depiction easier.
All electromagnetic waves travel at the same speed in a vacuum, irrespective of their energy
—the speed of light = 299 792 458 ms-1. The speed of any wave is related to its wavelength
and frequency by the following equation: speed = wavelength × frequency.
As the speed is known and constant (speed of light = c), the wavelength and frequency of
different electromagnetic waves must change accordingly. At one end of the spectrum, the
waves have a very long wavelength (and therefore low frequency) and are lower in energy. At
the other end, the waves have a very short wavelength, high frequency, and are very high in
energy (Fig 2-2).
Fig 2-1 The electromagnetic wave.
The electromagnetic spectrum is continuous. Although we name different parts of the

spectrum and provide cut-offs, these are arbitrary, and the different categories of waves differ
only in the energy they possess.
Fig 2-2 The electromagnetic spectrum (NASA).
Fig 2-3 A rotating anode X-ray tube.
Fig 2-4 Bremsstrahlung radiation production.
It is noticeable that visible light only makes up a narrow band in the spectrum. Waves with
frequencies below 4 × 1014 Hz are not visible to the human eye, and frequencies above 8 ×
1014 Hz are equally invisible. Above a certain energy level, the waves can become ionising
and cause damage to biological tissues. Higher-energy ultraviolet waves, X-rays, and gamma
rays all have enough energy to damage human cells.
Individual photons or continuous waves?

We have seen that electromagnetic waves are a continuous wave: however, we often refer to
‘photons’, which have a particulate form and particulate properties. This is an alternative way
of describing the interactions of electromagnetic waves more easily, and will appear
throughout the book. It should be noted, however, that the photons have no mass, and even
though they have particulate properties and can be described individually, they are in fact
discrete packets of energy.
X-ray production
X-rays are high-energy electromagnetic waves or photons. They occur naturally and are
emitted from some radioactive atoms; however, this is not amenable to everyday imaging, as
the radioactive source would deplete, and be constantly irradiating, and the amount and energy
of the radiation could not be easily controlled. Therefore, an artificial production method is
needed.
An X-ray tube contains several essential components, as illustrated in Figure 2-3 and listed
in Table 2-1, with a description of their purpose.
The X-rays are produced in two ways:
Bremsstrahlung
An incoming electron emitted from the Tungsten filament is accelerated through a vacuum
towards the Tungsten anode. As it strikes and passes through the anode, it may be attracted to
the positive nucleus of an individual Tungsten atom. This attraction will simultaneously deflect
the trajectory of the fast-moving electron and cause it to slow down rapidly. This rapid
deceleration and change of path results in energy loss, which is emitted as an X-ray photon.
The greater the deflection and slowing of the electron, the greater the resultant X-ray photon
energy. As each interaction between an individual electron and a nucleus of the Tungsten atom
in the anode is different and the energy loss is dissimilar, the energy profile of the X-rays
produced (the spectrum) is over a wide range.
The majority of X-rays—approximately 80%—from an X-ray tube are produced in this
method. It should be noted that the interaction here is between an incoming electron released
by the filament and the nucleus of the Tungsten atoms in the target (Fig 2-4).
Characteristic radiation
If the incoming electron passes close to the nucleus and has enough energy, it can knock out a
tightly bound inner shell electron (K shell) from the Tungsten atom. This leaves a vacant inner
shell, which is filled quickly by an outer shell (L or M shell) electron from the same atom. As
the outer shell electron ‘jumps down’ energy shells, it loses energy in the form of X-ray
radiation. In this case, the energy the outer electron needs to lose when ‘jumping’ to the inner
shell is a known amount for each different atom; so, the X-ray produced has exactly that amount
of energy. The outer shell electron may come from an L or M shell, so the energy will differ
slightly between the two. This is known as characteristic radiation—it is characteristic of that
particular atom (Fig 2-5). For Tungsten, the values for characteristic radiation are 58 keV and
68 keV.
Fig 2-5 Characteristic radiation production.
It should be noted that for characteristic radiation to be produced, the incoming electron
must have enough energy to knock out the inner K shell Tungsten electron. The inner Tungsten
electron needs 70 keV of energy to be knocked out; so only electrons with this amount of
energy or more have the chance to produce characteristic radiation with a Tungsten target. This
means that X-ray tubes operating below 70 kV will have no chance of producing characteristic
radiation. Cone beam computed tomography (CBCT) sets generally use 80 to 120 kV, which is
enough for characteristic radiation production with a Tungsten target.
Heat
The two interactions described above result in X-ray production; however, this is not the fate
of every electron released by the cathode that strikes the anode in the X-ray tube. About 99%
of energy is converted to heat, so only 1% of energy results in X-ray production. Therefore, X-
ray tubes are very inefficient at X-ray production. This large amount of heat energy is the
reason for heat removing devices such as the rotating anode (see motor in Fig 2-3) and outer
cooling oil.
Table 2-1 X-ray tube components and their purpose.
Component Purpose Notes

Tungsten Produces a supply of electrons by thermionic
Heats up via a low-voltage circuit to approx 2200°C
filament emission
Tungsten Large potential difference accelerates the electrons
anode/target for to a high speed, causing them to smash into the Component
electrons anode
This means excess heat created in the tube cannot be
Ensures the electrons can be accelerated
Vacuum lost by convection as there is no convection medium
uninterrupted
(air)
Lead casing Prevents X-rays leaving in other directions
Helps with heat dispersal and insulates the unit An oil leak is very serious and the tube must not be
Oil in outer case
electrically used
Rotating motor Rotates the anode, allowing a greater heat loading Spins at up to 10 000 rpm
Older, smaller dental sets may use mains AC
High-frequency Provides a near constant high kV and therefore
(alternative current), which is inefficient at X-ray
generator direct current
production
Tube window The only part of the lead casing that lets out X-rays Often aluminium, and contributes towards filtration
Fig 2-6 Bremsstrahlung spectrum profile.
Fig 2-7 Bremsstrahlung plus characteristic radiation.
Fig 2-8 Filtered profile; note the lower-energy photons to the left have been removed.
Spectrum profile
Bremsstrahlung radiation is produced over a wide range of energies up to the maximum tube
potential, as depicted in Figure 2-6.
If we use a tube operating at over 70 kV, then we also have characteristic X-rays, which are
at specific values (see Fig 2-7).
Filtering
Only the higher-energy photons that have the potential to pass through the patient and record at
the receptor are useful for imaging. The lower-energy photons are absorbed by the patient and
only contribute to dose. This is discussed again later on. Filtering is the process whereby
lower-energy photons are removed. The X-ray tube itself does some filtering by its inherent
properties; the rest is added, usually in the form of aluminium. It is normal to have about 2.5
mm aluminium-equivalent filtration.
The spectrum of a tube operating at 120 kV with filtration then looks like Figure 2-8, with
the lower-energy photons removed.
Altering the mA or kV
Changing the mA will result in more electrons being released from the cathode and accelerated
into the anode; however, the maximum energy of these electrons is still the same. Therefore, an
increase in mA causes an increase in the number of X-rays. The same effect is observed if the
exposure time is increased (Fig 2-9).
Changing the kV has two effects; firstly, the maximum energy of the electrons increases, so
higher-energy X-rays can be produced; secondly the anode pulls more electrons from the
filament, so the number of X-rays increases (Fig 2-10).
Summary
Double mA = double the number of X-rays
Double time = double the number of X-rays
Double kV = double the maximum X-ray energy and double the number of X-rays
For this reason, you may need to reduce the mA if you increase the kV.
Interaction with matter

When X-rays make contact with the patient, they can be absorbed, scattered or transmitted.
Absorbed X-rays
All the energy of the X-ray is deposited into the patient and the photon disappears completely.
This is called photoelectric absorption. This process occurs when the photon hits a tightly
bound inner electron of an atom in the patient. If the photon has more energy than the binding
energy of the inner shell electron, the electron can be knocked free and shoots off. This then
becomes a photoelectron (an electron with kinetic energy from the photon), and the photon
ceases to exist. An outer shell, electron from that atom will ‘jump down’ to fill the inner shell,
releasing a very small amount of energy (as a low-energy photon), which is deposited in the
tissue. The photoelectron will also deposit energy throughout the body tissues.
Fig 2-9 Double mA graph.
Fig 2-10 Double kV graph.
This interaction does not add to the image directly; however, in the areas where photons are
absorbed the most (e.g. bone), there will be a lower signal, which will contribute to the image
contrast (Fig 2-11a).
Scattered X-rays
There are two forms of scatter—Compton scattering and Rayleigh scattering. Rayleigh
scattering has little or no effect during diagnostic radiography, so we will discuss Compton
scattering only.
In this process, consider only the outermost electrons of the atoms in the patient; the ones
that are so far from the nucleus that they are very weakly bound. The incoming photon hits one
of these loosely bound electrons and gives up some energy to the electron. Thus, the electron
heads off in a new direction with the extra energy. The initial X-ray photon is deflected in this
collision, depending on the initial energy of the photon and how much energy it gives the
electron.
Scatter adds X-ray dose to the patient, as the scattered electron has enough energy to ionise
other cells and cause damage. The scattered X-ray photons also degrade the image as they have
an altered course (Fig 2-11b).
Transmitted X-rays
The X-ray photons pass straight through the patient and hit the image receptor. These photons
contribute directly towards the image (Fig 2-11c).
The chance of each process occurring depends on the energy of the incoming photon, the
physical density of the tissue through which the X-ray passes, the atomic number of the tissue,
and the electron density of the tissue.
Bone will attenuate X-rays more than soft tissue because it has a higher physical density, a
higher average atomic number, and a higher electron density. This means that an incoming X-
ray photon is more likely to be scattered in bone than in soft tissue, as there are more electrons
to hit. It will also absorb more, as the atomic number of bone is higher, which means there is
more likely to be photoelectric absorption (Table 2-2).
Table 2-2 X-ray and its various effects.
Factor Effect Notes

X-ray photon energy Less likely to have photoelectric absorption = Lowers dose, as the photons are more likely
increases lower image contrast to be transmitted
Tissue is higher density More likely to have Compton scatter
Tissue has higher average More likely to have photoelectric absorption =
atomic number better contrast
Fig 2-11 (a) Photoelectric absorption; (b) Compton scatter; (c) transmitted radiation.
Further reading
Ionising Radiation Regulations (1999): www.hse.gov.uk/radiation/ionising/legalbase.htm
Nemtoi A, Czink C, Haba D, Gahleitner A. Cone beam CT: a current overview of devices. Dentomaxillofac Radiol
2013;42:20120443.
Chapter 3
Cone Beam Computed Tomography
Simon C Harvey, Shanon Patel
The differences and similarities between multidetector computed

tomography and cone beam computed tomography
Multidetector computed tomography
Modern multidetector computed tomography (MDCT) is a feature of the third generation of
computed tomography (CT) machines. The description of the first, second, fourth and fifth
generation CT machines is beyond the scope of this book, and they are already described in
several available texts. The third generation CT machine came into existence around the late
1980s to early 1990s, and has been refined since then. In virtually all applications, the scanner
consists of a gantry, which contains the rotating X-ray source and detector array. In the centre
of the gantry is a circular aperture, through which the patient lying prone on a bed is advanced.
Other than the slow-moving bed on which the patient lies, there are no visible moving parts.
The basic layout is shown in Figure 3-1a.
CT in its most basic form uses a fan-shaped beam, takes individual axial slices of the
patient, and stitches them together to form the 3D volume. The technique is also called helical
scanning, due to the helical (spiral) nature of the rotation of the X-ray tube in relation to the
movement of the patient bed (Fig 3-1b).
An advancement of this technique is used in the CT machines found in hospitals today, and is
known as MDCT. The multidetector component describes several rows of detectors, which can
gather several axial slices during one rotation. To do this, the beam needs a third dimension
(Fig 3-2).
MDCT increases the speed of the exam compared to single slice CT; however, there are still
groups of axial slices that are stitched together to make up the 3D volume. Thus, the detector
and X-ray tube array must make several revolutions around the patient as s/he is advanced
through the machine, to image the whole field of view. Modern machines spin at around 2 Hz,
that is, two 360-degree revolutions per second. This is considerably faster than any CBCT
machine on the market, which may take 20 seconds to complete a single revolution.
Fig 3-1 (a) CT scanner; note the fan-shaped X-ray beam and the rotating X-ray source. (b) Helical CT scanner.
Exploring the Variety of Random
Documents with Different Content
England, but also tyranny and repression wherever they operate.
The indictment of George III, which at times approaches sublimity, is
in reality directed against the entire reactionary policy of
contemporary European statesmen and rulers. The doctrines of the
revolutionary Byron, already familiar to us in Don Juan, are to be
found in the ironic stanzas upon the sumptuous funeral of the king,
a passage admired by Goethe; respect for monarchy itself had died
out in a nobleman who could say of George’s entombment:
“It seemed the mockery of hell to fold

The rottenness of eighty years in gold.”
With all its broad humor, the satire is aflame with indignation. In this
respect the poem performed an important public service. In place of
stupid content with things as they were, it offered critical comment
on existing conditions, comment somewhat biassed, it is true, but
nevertheless in refreshing contrast to the conventional submission of
the great majority of the British public.
Much of what has already been pointed out with regard to the
sources and inspiration of Don Juan may be applied without
alteration to The Vision of Judgment, which is, as Byron told Moore,
written “in the Pulci style, which the fools in England think was
369
invented by Whistlecraft—it is as old as the hills in Italy.” The
Vision, being shorter and more unified, contains few digressions
which do not bear directly upon the plot; but it has the same
colloquial and conversational style, the same occasional rise into true
imaginative poetry with the inevitable following drop into the
commonplace, the same fondness for realism, and the same broad
370
burlesque. Hampered as it is by the necessity of keeping the
story well-knit, Byron’s personality has ample opportunity for
expression.
It is probable that Byron’s description of Saint Peter and the
371
angels owes much to his reading of Pulci. In at least one
instance there is a palpable imitation. Saint Peter in the Vision, who
was so terrified by the approach of Lucifer that,
“He patter’d with his keys at a great rate,

372
And sweated through his apostolic skin,”
suffered as did the same saint in the Morgante Maggiore who was
weary with the duty of opening the celestial gate for slaughtered
Christians:
“Credo che molto quel giorno s’affana:

E converrà ch’egli abbi buono orecchio,
Tanto gridavan quello anime Osanna
Ch’eran portate dagli angeli in cielo;
373
Sicchè la barba gli sudava e ’l pelo.”
In employing the realistic method in depicting the angels, Byron

seems to have caught something of Pulci’s grotesque spirit.
One line of the Vision,
“When this old, blind, mad, helpless, weak, poor worm,”
seems to imitate the opening of Shelley’s powerful Sonnet; England
in 1819, already quoted,
“An old, mad, blind, despised, and dying king.”
Professor Courthope has suggested that Byron’s Don Juan owes
374
something to the work of Peter Pindar. The evidence for the
relationship seems, however, to be very scanty. Wolcot never
employed the octave stanza, nor, indeed, did he ever show
evidences of true poetic power. The two men were, of course, alike
in that they were both liberals, both avowedly enemies of George
III, and both outspoken in their dislikes. But Byron seldom except in
parts of the Vision used the method of broad caricature so
characteristic of Pindar. In the Vision, too, occurs the only obvious
reference on Byron’s part to Pindar’s satire. He describes the effect
of Southey’s dactyls on George III, in the lines:
“The monarch, mute till then, exclaim’d, ‘What! What!

375
Pye come again? No more—No more of that.’”
The couplet recalls Pindar’s delightful imitations of that king’s

eccentric habit of repeating words and phrases. However, Byron’s
style in both Don Juan and the Vision is drawn more from Italian
than from English models.
The Vision of Judgment is, if we exclude Don Juan as being
more than satire, the greatest verse-satire that Byron ever wrote. It
is only natural then to compare the poem with other English satires
which have high rank in our literature. A practically unanimous
critical decision has established Dryden’s Absalom and Achitophel as
occupying the foremost position in English satire before the time of
Byron. Unquestionably this work of Dryden’s is admirable; it is witty,
pointed, and direct, embellished with masterly character sketches
and almost faultless in style. It does, however, suffer somewhat from
a lack of unity, due primarily to the fact that the narrative element in
the poem is subordinate to the description. Byron’s Vision, on the
other hand, has a single plot, which is carefully carried out to a
climax and a conclusion. Action joins with invective and description
in forming the satire. Thus the two poems, approximately the same
length if we consider only Part I of Absalom and Achitophel, give a
decidedly different impression. Dryden’s satire seems a panorama of
figures, while Byron’s has the coherence and clash of a drama.
Absalom and Achitophel is witty but seldom humorous; while
Byron joins caricature and burlesque to wit. The best lines in
Dryden’s poem, such as:
“Beggar’d by fools, whom still he found too late;

He had his jest, and they had his estate,”
excite admiration for the author’s cleverness, but rarely arouse a

smile; the Vision, the contrary, is full of buffoonery. Dryden’s sense
of the dignity of the satirist’s office did not permit him to lower his
style, and he never became familiar with his readers; the very
essence of Byron’s satire is its colloquial character.
Dryden kept his personality always in the background, while the
egotistical Byron could not refrain from letting his individuality lend
fire and passion to whatever he wrote. Thus the Vision, despite the
fact that it is the most cool of Byron’s satires, cannot be called calm
and restrained. Self-control, the will to subdue and govern his
impulses and prejudices, was beyond his reach. Fortunately in the
Vision he did take time to exercise craftsmanship, but he never
attained the polished artistry and firm reserve of his predecessor.
Certainly in urbanity, in dignity, and in justice Dryden is the superior,
just as he is undoubtedly less imaginative, less varied, and less
spirited than Byron.
The two satires are, then, radically different in their methods.
One is a masterpiece of the Latin classical satire in English, formal
and regular, and using the standard English couplet; the other is our
finest example of the Italian style in satire—the mocking, grotesque,
colloquial, and humorous manner of Pulci and Casti. Both are
effective; but one is inclined to surmise that the purple patches in
Absalom and Achitophel will outlast the more perfect whole of The
Vision of Judgment.
The probable results of the publication of a work of such a
sensational character had been foreseen by both Murray and
Longman. When the first number of The Liberal appeared containing
not only The Vision of Judgment but also three epigrams of Byron’s
on the death of Castlereagh, it was received by a torrent of hostile
criticism from the Tory press. The Literary Gazette for October 19,
1822, called Byron’s work “heartless and beastly ribaldry,” and added
on November 2, that Byron had contributed to the Liberal “impiety,
vulgarity, inhumanity, and heartlessness.” The Courier for October 26
termed him “an unsexed Circe, who gems the poisoned cup he
offers us.” On the Whig side, in contrast, Hunt’s Examiner for
September 29 spoke of it as “a Satire upon the Laureate, which
contains also a true and fearless character of a grossly adulated
monarch.”
Byron himself described it to Murray as “one of my best
376
things.” Later critical opinion has also tended to rank it very high.
Goethe called the verses on George III “the sublime of hatred.”
Swinburne, himself a revolutionist but no partisan of Byron’s,
exhausts superlatives in commenting on it: “This poem—stands
alone, not in Byron’s work only, but in the work of the world. Satire
in earlier times had changed her rags for robes; Juvenal had clothed
with fire, and Dryden with majesty, that wandering and bastard
muse. Byron gave her wings to fly with, above the reach even of
these. Others have had as much of passion and as much of humor;
Dryden had perhaps as much of both combined. But here, and not
elsewhere, a third quality is apparent—the sense of a high and clear
imagination.—Above all, the balance of thought and passion is
admirable; human indignation and divine irony are alike understood
and expressed; the pure and fiery anger of men at the sight of
wrong-doing, the tacit inscrutable derision of heaven.” Nichol, in his
life of Byron, says:—“Nowhere in so much space, save in some of
the prose of Swift, is there in English so much scathing satire.”
Two figures in Byron’s poem have been made the basis of a
shrewd comparison by Henley. He says: “Byron and Wordsworth are
like the Lucifer and Michael of The Vision of Judgment. Byron’s was
the genius of revolt, as Wordsworth’s was the genius of dignified and
useful submission; Byron preached the doctrine of private revolution,
Wordsworth the dogma of private apotheosis—Byron was the
passionate and dauntless ‘soldier of a forlorn hope,’ Wordsworth a
kind of inspired clergyman.” Byron’s sympathies in the Vision, as in
Cain, were undoubtedly with Lucifer, the rebel and exile, and his
poem will live as a satiric declaration of the duty of active resistance
to despotism and oppression.
CHAPTER X
“THE AGE OF BRONZE” AND “THE BLUES”
Byron’s Monody on the Death of Sheridan, written at Diodati on

July 17, 1816, and recited in Drury Lane Theatre on September 7,
was followed by a period of several years in which he ceased to
employ the heroic couplet in poetry of any sort. The reasons for this
temporary abandonment of what had been, hitherto, a favorite
measure, are not altogether clear, although his action may be
ascribed, in part, to his renunciation of things English and to the
influence upon him of his study of the Italians. During his residence
in Italy, Byron used many metrical forms: the Spenserian stanza,
ottava rima, terza rima, blank verse, and other measures in some
shorter lyrics and ephemeral verses. Not until The Age of Bronze,
which he began in December, 1822, did he return to the heroic
couplet of English Bards.
On January 10, 1823, Byron, then living in Genoa, wrote a letter
to Leigh Hunt, in which, among other things, he said: “I have sent to
Mrs. S[helley], for the benefit of being copied, a poem of about
seven hundred and fifty lines length—The Age of Bronze—or Carmen
Seculare et Annus haud Mirabilis, with this Epigraph—‘Impar
Congressus Achilli’.” By way of description, he added: “It is
calculated for the reading part of the million, being all on politics,
etc., etc., etc., and a review of the day in general,—in my early
English Bards style, but a little more stilted, and somewhat too full of
377
‘epithets of war’ and classical and historical allusions.” The work
as revised and completed contains 18 sections and 778 lines.
Originally destined for The Liberal, it was eventually published
anonymously by John Hunt, on April 1, 1823.
The Age of Bronze is, then, entirely a political satire, intended
chiefly as a counterblast to the recent stringent regulations of the
reactionary Congress of Verona (1822). It comprises, however, other
material: an introductory passage on the great departed leaders,
Pitt, Fox, and Bonaparte; frequent digressions treating of the
struggles for constitutional government then taking place in Europe;
and some lines attacking the landed proprietors in England for their
luke-warm opposition to foreign war. It is, in nearly every sense, a
timely poem, although the note of “Vanitas Vanitatum” sounded in
the early sections gives the satire a universal application.
For a comprehension of Byron’s motives in writing The Age of
Bronze, it is necessary to understand something of the situation in
Europe at the time. Following the numerous insurrections of 1820–
22 in Spain, Portugal, Naples, Greece, and the South American
States, the European powers, guided by the three members of the
Holy Alliance, Russia, Prussia, and Austria, sent delegates to meet at
Verona on October 20, 1822, for a consideration of recent
developments in politics. The leading figure at the conference was
Metternich, the Austrian statesman, although Francis of Austria,
Alexander of Russia, and Frederick William of Prussia were among
the monarchs present. Montmorenci, representing an ultra-royalist
ministry under Villiele, was there to look after the interests of
France; while England, deprived at the last moment of Castlereagh’s
services by his suicide, sent Wellington. The gathering finally
resolved itself into a conclave for the purpose of discussing the right
of France to interfere in the affairs of Spain, by restoring Ferdinand
VII, a member of the House of Bourbon, to the throne of which he
had been deprived by the Constitutionalists. Wellington, after
protesting against the agreement reached by the other envoys to
378
permit the interference of France, left the Congress, by Canning’s
instructions, in December. His withdrawal, however, did not affect
the ultimate decision of the Congress to stamp out revolt whenever
it assailed the precious principle of Legitimacy. War between France
and Spain broke out in 1823; Ferdinand VII was replaced upon his
tottering throne; and the despotic policy of Metternich triumphed,
for a time, over democracy. Canning’s only reply was to recognize
the independence of the rebellious colonies of Spain, and to assert
the belligerency of the Greeks, then fighting for their liberty against
the Turks.
It is to the year which saw the work of the Congress of Verona
that Byron’s secondary title, Annus haud Mirabilis, obviously refers.
In a striking passage in the beginning of the poem, he pays a tribute
to the mighty dead, contrasting, by implication, the leaders of the
Congress with the departed heroes: Pitt and Fox, buried side by side
in Westminster Abbey; and Napoleon,
“Who born no king, made monarchs draw his car.”
The summary which Byron presents of Napoleon’s career is full of
admiration for the fallen emperor’s genius, and of resentment at the
indignities which, according to contemporary gossip, he had been
compelled to undergo on St. Helena. The man “whose game was
empires and whose stakes were thrones” was forced, says the poet,
to become the slave of “the paltry gaoler and the prying spy.” The
passage is both an appreciation and a judgment, wavering, as it
does, between sympathy and condemnation for the conqueror who
burst the chains of Europe only to renew,
“The very fetters which his arm broke through.”
The reference to these giants of the past leads Byron naturally to a
glorification of such liberators as Kosciusko, Washington, and Bolivar,
and to a joyful heralding of revolutions in Chili, Spain, and Greece:
“One common cause makes myriads of one breast,

Slaves of the east, or helots of the west;
On Andes’ and on Athos’ peaks unfurl’d,
The self-same standard streams o’er either world.”
Under the influence of this enthusiasm he prophecies a liberal

outburst which will end in the regeneration of Europe.
Contrasted with the optimism of this aspiring idealism is Byron’s
gloom over the deeds of the Congress of Verona. The measures
advocated by this gathering, as we have seen, were reactionary and
autocratic; and Byron’s description of it, tinged with liberal
sentiment, is vigorously satirical. In the conference headed by
Metternich, “Power’s foremost parasite,” he can see nothing but a
body of tyrants,
“With ponderous malice swaying to and fro,

And crushing nations with a stupid blow.”
Many of the allusions in Byron’s sketches of the members recall the

language used by Moore in his Fables for the Holy Alliance. Moore’s
views of the situation in Europe agreed substantially with those of
Byron. Byron’s reference to the “coxcomb czar,”
“The autocrat of waltzes and of war,”
recalls Moore’s mention of that sovereign in Fable I:
“So, on he capered, fearless quite,

Thinking himself extremely clever,
And waltzed away with all his might,
As if the Frost would last forever.”
Byron accuses Louis XVIII, who was not present at the

Congress, of being a gourmand and a hedonist,
“A mild Epicurean, form’d at best

To be a kind host and as good a guest.”
The same idea is conveyed in Moore’s description of that king as,

“Sighing out a faint adieu
To truffles, salmis, toasted cheese.”
Especially painful to Byron was the report that Marie Louise (1791–
1849), Napoleon’s widow, who had been secretly married to her
chamberlain, Adam de Neipperg, had attended the Congress, and
had become reconciled to her first husband’s captors. One section of
the satire paints a picture of her leaning on the arm of the Duke of
Wellington, “yet red from Waterloo,” before her husband’s ashes
have had time to chill.
The most bitter, and, at the same time, the most just satire in
the poem is directed at the English landed gentry:
“The last to bid the cry of warfare cease,

The first to make a malady of peace.”
The rise in prices due to the long-continued war had fattened the
purses of the farmers and land-holders in England, and led them to
wish secretly for the continuance of the struggle. Byron attacks
severely their grudging assent to proposals of peace, and, in a
succession of rhymes on the word “rent,” points out the selfishness
of their position. The diatribe contains some of Byron’s most
passionate lines:
“See these inglorious Cincinnati swarm,

Farmers of war, dictators of the farm;
Their ploughshare was the sword in hireling hands,
Their fields manured by gore of other lands;
Safe in their barns, these Sabine tillers sent
Their brethren out to battle—why? for rent!”
Although an occasional touch of mockery reminds us of Don
Juan, The Age of Bronze, in method, shows a reversion to the
invective manner of English Bards. It can hardly be said, however,
that this later satire is any advance over the earlier poem. Its
allusions are now unfamiliar to the average reader, and the names
once so pregnant with meaning have faded into dim memories.
Although The Age of Bronze has sagacity and practicality, it lacks
unity and concentration. Without the vehement sweep of English
Bards, it is also too rhetorical and declamatory. Most readers, despite
the flash of spirit which now and then lights its pages, have found
the satire dull.
The Blues, so little deserving of attention in most respects, is
unique among Byron’s satires for two reasons: it is written in the
form of a play, and it employs the anapestic couplet metre, used by
Anstey and later by Moore. Byron’s first reference to it occurs in a
letter to Murray from Ravenna, August 7, 1821: “I send you a thing
which I scratched off lately, a mere buffoonery, to quiz the Blues, in
two literary eclogues. If published, it must be anonymously—don’t
let my name out for the present, or I shall have all the old women in
London about my ears, since it sneers at the solace of their ancient
379
Spinsterstry.” On September 20, 1821, he calls it a “mere
380
buffoonery, never meant for publication.” Murray, following his
usual custom with literature which was likely to get him into trouble,
cautiously delayed publication, and the poem was turned over to
John Hunt and printed in The Liberal, No. III (pages 1–24), for April
26, 1823. It was not attributed to Byron by contemporary critics,
most of them giving Leigh Hunt credit for the authorship.
There is nothing in Byron’s letters to explain the immediate
motive which led the poet to scribble a work so unworthy of his
genius. In his journal kept during his society life in London there are
several references to the “blues,” and later he made some
uncomplimentary allusions to them in Beppo and Don Juan. In a
sense his efforts to ridicule them seem to parallel the attacks of
Gifford on a coterie equally harmless and inoffensive.
In form the satire is a closet drama in two acts, each containing
approximately 160 lines. The characters represented are intended, in
many instances, for living persons. Thus, in the first act, which takes
place before the door of a lecture room, Inkel, who is apparently
Byron, converses with Tracy, who may be Moore. Within, Scamp,
probably Hazlitt, is delivering a discourse to a crew of “blues,
dandies, dowagers, and second-hand scribes.” Among the subjects
for discussion between the two men is Miss Lilac, a spinster, and
heiress, and a Blue, who is doubtless a caricature of Miss Milbanke,
the later Lady Byron. References to “Renegado’s Epic,” “Botherby’s
plays,” and “the Old Girl’s Review” indicate that Byron has returned
to some favorite subjects for his satire.
The second act is located at the home of Lady Bluebottle, who
resembles closely Lady Holland, the well-known Whig hostess and
one of Byron’s friends. Sir Richard Bluebottle, in a monologue,
complains of the crowd of,
“Scribblers, wits, lecturers, white, black, and blue,”
who invade his house and who are provided for at his expense. In
the scene which ensues, Inkel acts as a sort of interlocutor, with the
others as a chorus. Wordsworth, the “poet of peddlers,” is satirized
in the old fashion of English Bards as the writer who,
“Singing of peddlers and asses,

Has found out the way to dispense with Parnassus.”
Southey is referred to as “Mouthy.” Of the other figures, Lady

Bluemont is, perhaps, Lady Beaumont, and Miss Diddle, Lydia White,
“the fashionable blue-stocking.” When the party breaks up, Sir
Richard is left exclaiming,
“I wish all these people were damned with my marriage.”
On May 6, 1823, Byron finished Canto XVI of Don Juan. The
fourteen extant stanzas of Canto XVII are dated May 8th. Shortly
after he made preparations for his expedition to Greece, and, on July
23, 1823, sailed in the Hercules, with Gamba and Trelawney, for
Cephalonia. From this time on, his work in poetry practically ceased.
He wrote Moore from Missolonghi, March 4, 1824: “I have not been
quiet in an Ionian Island but much occupied with business.... Neither
381
have I continued Don Juan, or any other poem.” He devoted
himself to drilling Greek troops, holding conferences with leaders,
and corresponding with the patriot parties. A fever, brought on by
over-exposure, attacked him on April 11th, on the 19th, he died. His
remains were brought to England, and buried in the little church of
Hucknall Torquard, only a few miles from Newstead Abbey.
CONCLUSION
Mr. Augustine Birrell, in an illuminating essay on the writings of
Pope, brings forward, with reference to satire, a standard of
judgment which merits a wider application. “Dr. Johnson,” says Mr.
Birrell, “is more to my mind as a sheer satirist than Pope, for in
satire character tells more than in any other form of verse. We want
a personality behind—a strong, gloomy, brooding personality; soured
and savage if you will—nay, as sour and savage as you like, but
spiteful never.” Without subscribing unreservedly to Mr. Birrell’s
preference of Johnson over Pope, we may still point out that the
most conspicuous feature of Byron’s satire, as, indeed, of most of his
other poetry, is the underlying personality of the author, too
powerful and aggressive to be obscured or hidden. There have been
satirists who, in assuming to express public opinion, have succeeded
in partly or entirely effacing themselves, and who have thus acted in
the rôle of judicial censors, self-appointed to the task of voicing the
sentiments of a party. In the poetry of the Anti-Jacobin, it is by no
means easy to detect where the work of one Tory satirist leaves off
and that of another begins. So in Dryden’s work we are seldom
confronted directly by the emotions or partialities of the writer
himself; Absalom and Achitophel gives the impression of a cool
impersonal commentary on certain episodes of history, prejudiced
perhaps, but carried on with real or feigned calmness. Byron’s satire
is of a different sort; we can read scarcely a page without
recognizing the potency of the personality that produced it. Just as
in Childe Harold the hero usually represents Byron himself in some
of the phases of his complex individuality; just as the Lara and the
Corsair of his verse romances and the Cain and Manfred of his
dramas are reflections of the misanthropical, theatrical and skeptical
poet; so, in the satires, no matter what method he uses, it is always
Byron who criticises and assails.
Most of the characteristics which make up this personality
accountable for Byron’s satiric spirit have been brought out and
discussed in previous chapters. The most important of all, probably,
is the haste and impetuosity with which he was accustomed to act.
In this respect he may be again contrasted with Dryden, who
proceeded to satirize an enemy after due preparation, without
apparent agitation or excitement, much as a surgeon performs a
necessary operation. Even Pope, sensitive and irritable though he
was, did not usually strike when his temper was beyond his control.
Byron, on the other hand, was, in most cases, feverish and
impulsive; what he thought to be provocation was followed at once
by a blow. He did not adopt a position of unmoved superiority, but,
both too proud and too impatient to delay, sought instinctively to
settle a dispute on the spot. Except in some instances notable
because of their rarity, Byron seems to have had no understanding
of the method of toying with a prospective victim; he planned to
close with his opponent, to meet him in a grapple, and to overwhelm
him by sheer energy and intrepidity.
This want of restraint had, of course, some favorable results on
his satire; the work was indisputably vigorous, effective because of
the ungoverned passion which sustained it. At the same time this
hasty action was detrimental to Byron’s art, and accounts, in part,
for the frequent lack of subtlety in his satire. We may be roused
temporarily by the fury of the lines; but when, in less enthusiastic
moods, we examine the details, we miss the technique and the
transforming craftsmanship of the supreme artist. Only in The Vision
of Judgment did he devote himself to devising means for gaining his
end in the most dexterous fashion; and the consequence is that
poem is the finest of his satires. In the earlier satires we have Byron,
the man, talking out spontaneously, angrily, unguardedly, without
second thought or reconsideration, like Churchill, a mighty wielder of
the bludgeon but a poor master with the rapier.
Byron’s satiric spirit was always combative rather than
argumentative or controversial. He preferred to assail men rather
than principles. When he disliked an institution or a party, his
invariable custom was to select some one as its representative and
to proceed to call him to account. It is this desire to war with
persons and not with theories that explains his attacks on
Castlereagh, whom he never knew, but whom he singled out as the
embodiment of England’s repressive policy. By nature Byron was
much more ready to quarrel with the Foreign Minister as an
individual than he was to discuss the prudence and expediency of
that statesman’s measures.
The characteristics so far mentioned could belong only to a
daring and fearless man. Byron never hesitated to avow his ideas,
nor did he ever retract his invective except in cases in which he had
been convinced that he was unjust. He published the Lines to a Lady
Weeping under his own name at a time when no one suspected his
authorship. For years he satirized European sovereigns without
showing the slightest sign of trepidation. He espoused unpopular
causes, and often, of his own choice, ran close to danger, when
mere silence would have assured him security.
But despite the fact that Byron’s hatreds were seldom disguised
and that he was, on the whole, open and manly in his satire, there is
another side to his nature which cannot be left unnoticed. He was,
unfortunately, implicated in certain incidents which leave him under
the suspicion of a kind of treachery towards his friends. His lampoon
on Samuel Rogers, beginning,
“Nose and chin would shame a knocker;

Wrinkles that would puzzle Cocker;”
and ending,
“For his merits, would you know ’em?
Once he wrote a pretty Poem,”
unpublished during his lifetime, was nevertheless a malicious squib

directed at a man who had been one of his closest companions.
There can be no doubt, too, that Byron’s satiric ballad on Hobhouse,
“My boy Hobbie, O,” sent secretly to England, was a true stab in the
back, administered to the man who had been his loyal friend. Byron,
moreover, was not always accurate in his charges. Like most
satirists, he exaggerated to gain his point, and made claims which
the evidence did not justify. Nor is it in his favor that he chose to
attack his wife in public lampoons, and wrote scurrilous epigrams
upon dead statesmen.
This lack of delicacy aside, however, it must be recognized that
Byron’s satire was often exerted in condemning real evils, and that
he performed a definite service to humanity. More than any other
man of his time he insisted on liberty of speech and action in a
period when reactionary politicians were in the ascendant. He
combated the perennial forms of hypocrisy and cant which appear
constantly in England. Neither Dryden nor Pope had been the
consistent champion of great causes; but Byron so often employed
his satire for beneficial purposes that, despite the vituperation with
which it was greeted by conservatives, it became a powerful
influence for good.
It may be said, in general, of the substance of Byron’s satires,
that he devoted very little attention to the faults and foibles of
mankind, taken as a whole. He was usually moved to satire by some
contemporary person, event, or controversy, and his criticism was
definite, levelled at some specific abuse or evil. In his youth he
showed a disposition to take a lofty moral stand, and to preach
against vice; but he was ill-suited to didacticism, and soon forsook it
altogether. After 1812, his satire had a very intimate connection with
the life around him in politics, society, and literature, and reflected
the manners and moods of the age. It is to be noted, too, that Byron
was, in theory at least, in opposition to the spirit of his time. His
belief in liberal doctrines led him to resist much that seemed safe
and solid to those in his own class of life. He was not, in his later
days, in sympathy with the situation in Europe; and he died too soon
to see his progressive ideas bear fruit in the revolutions of 1830 and
the Reform Bill of 1832.
In literature Byron satirized, throughout his career, the
representatives of the older romantic school: Wordsworth, Coleridge,
and Southey. He did this mainly on the ground that their principles
of poetry were subversive of the rules handed down by his avowed
masters, Pope and Gifford. In thus defending the name and
doctrines of Pope, Byron was consistent during his literary lifetime,
although he himself wandered from the path which he persistently
asserted to be the only right one. In inveighing against Southey, he
was, of course, animated largely by personal spite. For minor
poetasters, scribblers who might have been made the puppets of a
modern Dunciad, Byron had little but silent contempt. In literary
satire, then, he presents the strange spectacle of a radical striving
desperately to support a losing cause, and that cause a conservative
one. Progressive in nearly every other respect, Byron persisted in
opposing any attempt to deviate from the standard established by
Pope.
Byron’s satire on society was partly the result of pique. He who
had been for some time its idol, found himself expelled from English
society, and, in retaliation, exposed its absurdities and follies. At the
same time it is unquestionable that he furthered a reform in
ridiculing the cant and sham of English high life. It was in his last
saner days that he wrote the cantos of Don Juan which treat of the
all-pervasive hypocrisy of fashionable circles, and the satire, even to-
day, rings true. It is noticeable that he seldom satirizes fads or
fashions, and that he rarely, after 1812, attacks private immorality.
His zeal is devoted to unveiling pretence, and to describing this
outwardly brilliant gathering as it really is.
Since Byron was a radical and a rebel, his satire was devoted, so
far as it concerned itself with political questions, to the glorification
of liberty in all its forms, and to the vigorous denunciation of
everybody and everything that tended to block or discourage
progressive movements. In defence of freedom and in resistance to
oppression, his satire found its fullest mission and its amplest
justification. When continental Europe of the middle nineteenth
century thought of Byron, it pictured him as a nobleman who had
assailed tyrannical monarchy, who had aided Italy and Greece in
their struggles for independence, and who had been willing to fight
for the sake of the principles in which he believed. The words of
Byron’s political creed have a noble ring: “The king-times are fast
finishing. There will be blood shed like water, and tears like mist; but
the peoples will conquer in the end. I shall not live to see it, but I
foresee it.”
The broader philosophical satire on humanity in which he was
more and more inclined to indulge as he reached maturity is
essentially shallow and cynical. As soon as Byron became indefinite,
as soon as he undertook to preach, he grew unsatisfactory, for he
had no lesson to teach beyond the pessimism of Ecclesiastes.
All these objects for satire afforded Byron an opportunity for
expressing some much-needed criticism. The most unworthy
sections of his satire are those devoted to mere revenge: the
unchivalric lines on Lady Byron and Mrs. Clermont; the violent abuse
of Southey and Jeffrey; and the treacherous thrusts at Rogers and
Hobhouse. In these passages the satirist descends to the lower level
of Churchill and Gifford.
It remains to say a word of Byron’s methods, a word merely of
recapitulation. Preferring directness always, he was inclined by
nature to go straight to his goal, to speak his mind out without
pausing to devise subtle or devious plans of attack. Except in his
Italian satires his procedure was simple enough: he hurled epithets,
made scandalous and scurrilous charges, and thought out offensive
comments, writing usually in the first person and meeting his
enemies face to face in the good old way of his eighteenth century
predecessors. It is, perhaps, unsafe, with Don Juan and The Vision
of Judgment before us, to assert that he was incapable of finesse
and cunning; but, for the most part, even in these poems, he was
more fond of abuse than he was of innuendo and crafty insinuation.
His impetuosity and irrepressible impulsiveness, to which we have
had occasion so often to refer, did not allow him to dwell
scrupulously on artistic effects.
He had, however, two distinct satiric moods: the one, savage,
stern, and merciless; the other, mocking, scornful, and humorous.
The one resulted in invective, the other, in ridicule and burlesque.
One came to him from Juvenal, Pope, and Gifford; the other he
learned from Moore, Frere, and the Italians. Thanks to his versatility,
he was successful in using both; but his real genius was shown more
in the contemptuous mirth of The Vision of Judgment than in the
fury of English Bards.
Unlike Pope, Byron was no adept at framing pointed phrases.
The beauty of Pope’s satire lies in the single lines, in the details and
the finish of an epithet. Byron’s work, on the other hand, should be
estimated with regard to the general effect. Few recall particular
lines from the passage on Southey in The Vision of Judgment; yet
every one remembers the complete caricature of the laureate. Pope
manipulated a delicate and fine stencil; Byron painted on the canvas
with broad sweeping strokes.
Byron was the last of the great English satirists in verse, and he
has had no imitators who have been able to approach his unique
style and manner. It is a curious fact that his influence after his
death on nineteenth-century English satire has been almost
negligible. The causes of this decline in satire since Byron’s day are
not altogether easy to explain. Perhaps it may be accounted for as
accompanying the general lack of interest in poetry of any sort so
common to-day. Possibly it may be due to the stringency of the laws
against libel, which has resulted in the situation described by Sir
George Trevelyan in his Ladies in Parliament:
“But now the press has squeamish grown, and thinks invective
rash:
And telling hits no longer lurk ’neath asterisk and dash;
And poets deal in epithets as soft as skeins of silk,
Nor dream of calling silly lords a curd of ass’s milk.”
In the twentieth century great political problems are usually fought

out in the newspapers or in prose pamphlets; the editorials of our
daily journals take the place of satires like The Age of Bronze.
Doubtless, too, we have grown somewhat refined in our sensibilities
and fastidious in our speech, so that we shrink from the cut-and-
slash method in poetry. At any rate our English satire since 1830 has
inclined toward raillery and humor, wholly unlike the ardent
vindictiveness of the men under the Georges. The old régime died
away with Byron; and in its stead we have had the polished
cleverness of Praed, the gentle cynicism of Thackeray, the mild
sentimentality of Looker and Dobson. Not until very recently have
flashes of the invective spirit appeared in the work of William
Watson and Rudyard Kipling. The great issues of the twentieth
century have stimulated no powerful English satirist in verse.
BIBLIOGRAPHY
The standard edition of Byron’s Poetical Works is that by Ernest
Hartley Coleridge in seven volumes (London, 1904), which contains
an exhaustive bibliography of the successive editions and
translations of different poems. The most complete collection of the
Letters and Journals is that by Rowland E. Prothero in six volumes
(London, 1902). Any study of Byron must be largely based on these
comprehensive and scholarly works. A fairly detailed list of critical
articles on Byron was compiled by Roden Noel in his Life of Lord
Byron; this, however, needs to be supplemented and revised in the
light of recent investigation.
The following list includes only the more important sources of
information for this treatise.
Ackermann, R. Lord Byron, Heidelberg, 1901.

Anti-Jacobin, Poetry of the, edited by Charles Edmonds, London,
1890.
Armstrong, J. L. Life of Lord Byron, London, 1858.
Arnold, Matthew. Byron (In his Essays in Criticism, Second
Series, London, 1903).
Austin, Alfred. A Vindication of Lord Byron, London,
1869.
Byron and Wordsworth (In his Bridling of
Pegasus, London, 1910.)
Bell, John. Fugitive Poetry, London, 1790. 18 vols.
in 9.
Beyle, Henri. Lord Byron en Italie (In his Racine, Paris,
1854).
Bleibtreu, K. Byron der Uebermensch, Sein Leben und
sein Dichten, Jena, 1897.
Blessington, Lady. Conversations with Lord Byron, London,
1834.
Brandes, G. Main Currents in 19th Century Literature,
London, 1905.
Brydges, Sir Samuel E. Letters on the Character and Poetical
Genius of Lord Byron, London, 1824.
An Impartial Portrait of Lord Byron, as a
Poet and a Man, Paris, 1825.
Buratti, P. Poesie, Venezia, 1864. 2 vols.
Castelar, E. Life of Lord Byron, and Other Sketches,
London, 1875.
Casti, G. B. Gli Animali Parlanti, Londra, 1803. 2
Tome.
Novelle, Parigi, 1804. 3 volumi.
Il Poema Tartaro, Milano, 1871.
Chasles, V. E. P. Vie et influence de Byron sur son époque
(In his Études sur l’Angleterre au XIX
siècle, 1850.)
Chesterton, G. K. The Optimism of Byron (In his Twelve
Types, London, 1903.)
Churchill, C. Poetical Works, Boston, 1854. (Ed. by
Tooke.)
Clinton, G. Memoirs of the Life and Writings of Lord
Byron, London, 1825.
Collins, J. C. Studies in Poetry and Criticism, London,
1905.
Courthope, W. J. The Liberal Movement in English
Literature, London, 1885.
A History of English Poetry, London,
1895–1910. 6 vols.
Dallas, R. C. Recollections of the Life of Lord Byron,
1808–1814, London, 1824.
Edgcumbe, R. Byron, the Last Phase, New York, 1909.
Eichler, A. John Hookham Frere; Sein Leben und
seine Werke; Sein Einfluss auf Lord
Byron, Wien und Leipsig, 1905.
Elze, Karl. Lord Byron: A Biography, London, 1872.
Esteve. Byron et le Romantisme français, Paris,
1907.
Frere, J. H. Works, London, 1872. 2 vols.
Fuhrman. Die Belesenheit des jungen Byron.
Galt, John. The Life of Lord Byron, London, 1830.
Gamba, P. A Narrative of Lord Byron’s Last Journey
to Greece, London, 1825.
Gifford, W. The Baviad and the Mæviad, London,
1797.
Gilfillan, G. A Second Gallery of Literary Portraits,
London, 1850.
Guiccioli, Countess. Lord Byron jugé par les temoins de sa
vie, Paris, 1868.
Hancock, A. E. The French Revolution and the English
Poets, New York, 1899.
Hannay, J. Satire and Satirists, London, 1854.
Hazlitt, W. The Spirit of the Age, London, 1825.
Hunt, L. Lord Byron, and Some of his
Contemporaries, London, 1828. 2 vols.
Jack, A. A. Poetry and Prose, London, 1912.
Jeaffreson, J. C. The Real Lord Byron, Leipsig, 1883. 3
vols.
Kennedy, James. Conversations on Religion, with Lord
Byron and Others, London, 1830.
Koeppel, E. Lord Byron, Berlin, 1903.
Medwin, T. Journal of the Conversations of Lord
Byron, London, 1824.
Moore, Thomas. Letters and Journals of Lord Byron, with
Notices of his Life, London, 1830.
Memoirs, Journal, and Correspondence,
London, 1856. 8 vols.
More, P. E. The Wholesome Revival of Byron. (In the
Atlantic. Vol. 82, December, 1898.)
Nichol, J. Byron, London, 1908. (Eng. Men of
Letters Series.)
Parry, W. The Last Days of Lord Byron, London,
1825.
Pope, A. Poetical Works, London, 1895. 10 vols.
Previte-Orton, C. W. Political Satire in English Poetry,
Cambridge, 1910.
Pulci, L. Morgante Maggiore, Venezia, 1784.
Pyre, J. F. A. Byron in our Day. (In the Atlantic, Vol.
99, April, 1907.)
Roever. Lord Byrons Gedanken ueber Alexander
Pope’s Dichtkunst, Hanover, 1886.
Stephen, L. Byron (In Dict. of Nat. Biog., Vol. viii.,
pp. 132–155).
Swinburne, A. C. Essays and Studies, London, 1875.
Miscellanies, London, 1886.
Trelawney, E. J. Recollections of the Last Days of Shelley
and Byron, London, 1858.
Records of Shelley, Byron, and the
Author, London, 1878.
Trent, W. P. The Byron Revival. (In the Forum, Vol.
26, October, 1898.)
Tucker, S. M. Verse Satire in England before the
Renaissance, New York, 1906.
Weddigen, O. Lord Byrons Einfluss auf die
europaischen Litteraturen der Neuzeit,
Hannover, 1884.
FOOTNOTES
1
That satire is primarily destructive criticism was asserted by
Heinsius in a familiar passage quoted approvingly by Dryden in
his Essay on Satire:—“Satire is a kind of poetry—in which
human vices, ignorance, and errors, and all things besides,
which are produced from them in every man, are severely
reprehended.” The same theory is expressed by De Gubernatis
in his Storia della Satira:—“La satira è, sovra ogni cosa, una
negazione.”
2
See Poetry, VII, 1.
3
In the Preface to Absalom and Achitophel, Dryden is inclined
to take pride in his fairness:—“I have but laughed at some
men’s follies, when I could have declaimed against their vices;
and other men’s virtues I have commended, as freely as I
have taxed their crimes.”
4
Epilogue to the Satires, Dialogue II., 212–217.
5
See Chesterton’s Pope and the Art of Satire.
6
Both methods are illustrated in a line of the Dunciad:—
“My H—ley’s periods, or my Blackmore’s numbers.”
7
In the Dramatis Personæ of Absalom and Achitophel only two
women appear, and they are spoken of in the poem in a
complimentary way.
8
Byron particularly emphasizes the correctness and moral tone
of Pope: he is “the most perfect of our poets and the purest of
our moralists” (Letters, v., 559); “his moral is as pure as his
poetry is glorious” (Letters, v., 555); “he is the only poet that
never shocks” (Letters, v., 560).
9
Gay’s Alexander Pope, his safe Return from Troy (1720) is
interesting as being one of the rare examples of the use of the
English octave stanza between Lycidas and Beppo.
10
Letters, v., 252.
11
In speaking of the art of rhyming to Trelawney, Byron said:
—“If you are curious in these matters, look in Swift. I will send
you a volume; he beats us all hollow, his rhymes are
wonderful.”
12
Cf. Swift’s The Puppet Show with Byron’s Inscription on the
Monument of a Newfoundland Dog.
13
For a contemporary characterization of the unscrupulous
satirists of the period see Cowper’s Charity, 501–532, in the
passage beginning,
“Most satirists are indeed a public scourge.”
14
Examples are The Thimble (1743) by William Hawkins (1722–
1801) and the Scribleriad (1752) by Richard Owen Cambridge
(1717–1802).
15
State Dunces (1733) and The Gymnasiad (1738) by Paul
Whitehead (1710–1744); The Toast (1736) by William King
(1685–1763); and a succession of anonymous poems, The
Battle of the Briefs (1752), Patriotism (1765), The Battle of the
Wigs (1763), The Triumph of Dulness (1781), The Rape of the
Faro-Bank (1797), and The Battle of the Bards (1799).
16
The most important is Churchill’s Rosciad (1761), with the
numerous replies which it elicited: the Churchilliad (1761), the
Smithfield Rosciad (1761), the Anti-Rosciad (1761), by Thomas
Morell (1703–1784), and The Rosciad of Covent Garden
(1761) by H. J. Pye (1745–1813). Among other satires of the
same class may be mentioned the Smartiad (1752) by Dr. John
Hill (1710–1775), with its answer, the severe and effective
Hilliad (1752) by Christopher Smart (1722–1771); the
Meretriciad (1764) by Arthur Murphy (1727–1806); the
Consuliad (1770), a fragment by Chatterton; the Diaboliad
(1777), with its sequel, the Diabolady (1777) by William
Combe (1741–1823); and finally the Criticisms on the Rolliad,
Gifford’s Baviad and Mæviad, the Simpliciad, and the
Alexandriad (1805).
17
The Scandalizade (1750); The Pasquinade (1752) by William
Kenrick (1725–1779); The Quackade (1752); The Booksellers
(1766); The Art of Rising in the Church (1763) by James Scott
(1733–1814); The Senators (1772); and The Tribunal (1787).
18
A few typical controversial satires of this decade are: The Race
(1762) by Cuthbert Shaw (1739–1771); The Tower (1763);
The Demagogue (1764) by William Falconer (1732–1769); The
Scourge (1765); and The Politician (1766) by E. B. Greene
(1727–1788).
19
Some characteristic examples are the Epistle to Cornbury
(1745) by Earl Nugent (1702–1788); the Epistle to William
Chambers (1773) and the Epistle to Dr. Shebbeare (1777) by
William Mason (1724–1797); and the Epistle to Dr. Randolph
(1796), as well as numerous other epistles, by T. J. Mathias.
20
See Macaulay’s Essay on Horace Walpole, page 35.
21
An Essay on the Different Styles of Poetry (1713) by Thomas
Parnell (1679–1718); The Danger of Writing Verse (1741) by
William Whitehead (1715–1785); A Prospect of Poetry (1733);
The Perils of Poetry (1766); and The Wreath of Fashion (1780)
by Richard Tickell (1751–1793).

60673

Uploaded by

Copyright:

Available Formats

60673

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

60673

Uploaded by

Copyright:

Available Formats

Download the full version of the ebook at ebookfinal.

Cone Beam Computed Tomography in Endodontics 1º

Download more ebook instantly today at https://ebookfinal.com

The Principles of Endodontics 2nd Edition Shanon Patel

MacMillan Destination C1 C2 Grammar Vocabulary Malcolm

Kalender Willi A Computed Tomography 3rd edition Publicis

Theory of Beam Columns Volume 1 In Plane Behavior and

Endodontics problem solving in clinical practice 1st

College practical chemistry Patel

Annual Reports on NMR Spectroscopy Volume 83 1st Edition

Recent Exploration in Indian English Writings M. F. Patel

Shanon Patel · Simon Harvey · Hagay Shemesh · Conor Durack

Quintessence Publishing Co. Ltd,

The editors would like to thank the following:

Francesco Mannocci, per i tuoi saggi consigli;

Professor Paul MH Dummer BDS, MScD, PhD, DDSc,

Professor of Restorative Dentistry,

Chapter 1 The Limitations of Conventional Radiography and Adjunct

Chapter 2 Radiation Physics

Chapter 3 Cone Beam Computed Tomography

Chapter 4 Using CBCT: Dose, Risks and Artefacts

Chapter 5 Dentoalveolar Anatomy

Chapter 6 Assessment of Root Canal Anatomy

Chapter 7 Apical Periodontitis

Chapter 9 Traumatic Dental Injuries

Chapter 10 Root Resorption

Limitations of conventional radiographic imaging

Advanced radiographic techniques for endodontic diagnosis

Magnetic resonance imaging

Tuned aperture computed tomography

Cone beam computed tomography

The electromagnetic wave

The electromagnetic spectrum is continuous. Although we name different parts of the

Fig 2-2 The electromagnetic spectrum (NASA).

Fig 2-4 Bremsstrahlung radiation production.

Individual photons or continuous waves?

The X-rays are produced in two ways:

Fig 2-5 Characteristic radiation production.

Component Purpose Notes

Fig 2-6 Bremsstrahlung spectrum profile.

Interaction with matter

Fig 2-10 Double kV graph.

Factor Effect Notes

The differences and similarities between multidetector computed

“It seemed the mockery of hell to fold

“He patter’d with his keys at a great rate,

“Credo che molto quel giorno s’affana:

In employing the realistic method in depicting the angels, Byron

“The monarch, mute till then, exclaim’d, ‘What! What!

The couplet recalls Pindar’s delightful imitations of that king’s

“Beggar’d by fools, whom still he found too late;

excite admiration for the author’s cleverness, but rarely arouse a

Byron’s Monody on the Death of Sheridan, written at Diodati on

“One common cause makes myriads of one breast,

Under the influence of this enthusiasm he prophecies a liberal

“With ponderous malice swaying to and fro,

Many of the allusions in Byron’s sketches of the members recall the

“So, on he capered, fearless quite,

Byron accuses Louis XVIII, who was not present at the

“A mild Epicurean, form’d at best