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Home » Case Studies » Beyond X-Rays: how InnerView Reveals hidden Structural Issues Before Symptoms Appear

Beyond X-Rays: how InnerView Reveals hidden Structural Issues Before Symptoms Appear

Howard Golan, DDS

5 minute read · March 18, 2025

The information below refers to future capabilities, currently under development andclinical evaluation. Not yet FDA cleared.

Patient Case: Undiagnosed Structural Defects Identified with InnerView®

The Challenge

A 63-year-old patient presented with sensitivity in the upper right when biting and with cold exposure. Traditional exams and X-rays were inconclusive.

Traditional Diagnostic Methods & Limitations

The patient presented with generalized hypersensitivity, making cold testing unreliable. Standard diagnostic tools provided inconclusive results:
  • X-rays & CBCT: Tooth #2 showed signs of periapical pathology (PAP).
  • Recurrent decay distal margin of tooth #4 crown. 
  • Percussion Test: Negative response when tapping with a mouth mirror.
  • Tooth Sleuth Test: Positive for Tooth #4 in the central groove, but no clear diagnosis for other teeth.
  • Restorations: Teeth #3, #4, and #5 had full-coverage restorations, making visual assessment difficult.
  • Grinding & Clenching: Patient exhibited occlusal wear that could contribute to symptoms.

Planned Treatment Based on Traditional Diagnostics

  • Tooth #4 was treatment planned for a new crown and core buildup due to radiographic decay.
  • Tooth #2 was scheduled for a root canal treatment (RCT), post, and crown.
  • Tooth #5 appeared clinically and radiographically normal.

How InnerView® Changed the Diagnosis

The InnerView® Examination Process

Unlike traditional diagnostics, InnerView® provides quantifiable data on tooth structural integrity and implant stability. The handpiece delivers four percussive taps to the tooth or an implant at any stage, and measures the energy return to detect:

  • Mobility in the overall tooth structure (enamel, dentin, cementum, PDL).
  • Defects in restorations and substructures that are undetectable by X-rays or visual inspection.
  • Early signs of failure before symptoms appear.

What InnerView® Revealed

  • Tooth #4: High measurements values confirming the need for restoration replacement
  • Tooth #5: Unexpected structural instability detected, despite showing no issues in Xrays or clinical exams.
InnerView’s findings suggested hidden structural defects that would have been missed with conventional methods.

How InnerView® Changed the Diagnosis

Mobility

Displayed you see the Mobility numbers of teeth 2-6. Mobility is on a scale of 0 to 100, preferred value in the mid-range. A high reading indicates high mobility.

Normal Fit Error (NFE)

This image shows the InnerView app displaying NFE on teeth 2-6 tested prior to dental work. You can see high NFE numbers for teeth numbers 4 and 5. The NFE scale is from 0 (associated with an intact structure of structural abnormality) to 150 (indicating localized micro-movement).

*NFE measurements are used in clinical research- Not yet FDA cleared.

Energy Return Graphs: Confirming Structural Instability

An undamaged tooth or implant is indicated by an energy return graph (ERG) with a normal bell-shaped curve. If the shape, such as is seen in this image for tooth #4, there is a need for further clinical evaluation to determine the underlying cause.
This data – although currently under development and not yet FDA cleared – indicates micromovement within the tooth system, suggesting hidden structural defects. These findings prompted a more cautious approach to the restoration, ensuring that additional structural issues could be addressed once the existing crown was removed.

Here you see, in light blue, a gaussian curve, representing an un-damaged tooth. Second, you also see the actual Energy Return Graph (ERG) of the damaged tooth, in dark blue. When the two images are compared, the area of the ERG that does not match up is turned into the NFE value, which helps identify structural instability.

Treatment Plan Adjustments: The Hidden Issue with Tooth #5

While Tooth #4 was already scheduled for crown replacement, Tooth #5 had shown no signs of structural issues in X-rays or traditional exams. However, InnerView’s readings indicated localized mobility within the tooth structure that had been previously unnoticed.

Had InnerView® not identified these early signs, Tooth #5 could have remained untreated until symptoms developed at a point of greater tooth damage —potentially leading to pain, fractures, or complete restoration failure.

Intraoperative Findings: What Was Discovered During Treatment?

Tooth #4: Verifying Structural Integrity Post-Crown Removal

  • The crown was removed as originally planned, but the tooth visually appeared intact.
  • Due to InnerView’s findings, the core was carefully assessed and reinforced to prevent future complications.
  • The patient was informed beforehand that a core buildup would be necessary based on the ERG results.
  • Unexpected fracturing of the all-ceramic restoration occurred immediately upon bur penetration.

Tooth #5: InnerView’s Prediction Confirmed

  • Typically, an intact ceramic crown takes time to cut through, but instant breakage indicated a pre-existing defect—precisely what InnerView had detected.
  • Upon further examination, the core buildup was found to be loose, confirming InnerView’s structural mobility reading.
  • The existing core was removed and replaced with a new bonded core, ensuring longterm stability.

Post-Treatment InnerView® Examination: Measuring the Impact of Treatment

Following treatment, a new InnerView® scan was conducted to assess whether the structural integrity had improved. The results were conclusive:
  • Tooth #4’s mobility readings significantly decreased, confirming the new restoration had stabilized the tooth.
  • Tooth #5, which had shown hidden mobility, now demonstrated structural integrity post-core replacement.
  • Provisional restorations were placed because the post-op readings were taken immediately after, not with permanent crowns
  • The new restorations were properly sealed and reinforced, preventing future failures. These results validated InnerView’s role in identifying issues that traditional exams had missed, ensuring proactive treatment rather than reactive repair.
Pre NFE
Post NFE
Pre Mobility
Post Mobility

Displayed is a clear example of improved results in NFE, blue lines, for both #4 and #5.

Key Takeaways: Why InnerView® is a Game-Changer in Diagnostics

Traditional diagnostic tools (X-rays, percussion, CBCT) failed to detect early-stage issues in Tooth #5.
  • InnerView® identified hidden mobility and structural instability—leading to earlier, more effective treatment.
  • Post-treatment scans confirmed that stability had been restored, preventing future complications.

The Future of Dental Diagnostics

Without InnerView®, Tooth #5 would have remained untreated, leading to:
  • Delayed intervention until severe symptoms developed
  • Potential restoration failure or fracture
    Additional cost & discomfort for the patient
InnerView® enables clinicians to:
  • Detect early-stage structural defects before symptoms appear
  • Make more informed, data-driven treatment decisions
  • Monitor trends in tooth and implant stability over time
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