Radiographic Examination

Outline
Introduction Interpretation of Normal Radiographs Normal Landmarks Periapical Radiographs Complete Mouth Radiographs Posterior Bitewing Radiographs Supplemental Radiographs Radiographs for Children Dangers from Radiation

Introduction

Introduction
Radiographic Examination - most commonly omitted - (initial examination) complete mouth radiograph, posterior bitewing radiographs - separate fee is charged

Interpretation of Normal Radiographs

- normal should always be understood - it is the architecture of the hard tissues - radiopacity or radiolucency may be seen - two-dimensional shadow of structures - superimposition may occur

Radiopaque areas appear lighter, shadow of dense structures

Normal Landmarks Periapical Radiographs

The Maxilla
1. Incisive Foramen

Oval shaped radiolucent area between the roots of the maxillary incisor teeth

Normal Landmarks Periapical Radiographs

The Maxilla
2. Nasal Septum

Vertical Radiopaque band above the apices of the central incisors

Normal Landmarks Periapical Radiographs

The Maxilla
3. Incisive Fossa/Lateral Fossa

Radiolucent area between the roots of the cuspid and central incisor and over the apex of the lateral incisor

Normal Landmarks Periapical Radiographs

The Maxilla
4. Maxillary Sinus

Radiolucent area extending from the Premolar Area posteriorly to the second molar region

Normal Landmarks Periapical Radiographs

The Maxilla
4a. Sinus Septa 4b. Antral Y

Radiopaque lines running through the maxillary sinus

Radiopaque line marks the separation of the anterior portion of the maxillary sinus from the nasal cavity

Normal Landmarks Periapical Radiographs

The Maxilla
5. Malar Bone

U-shaped radiopaque band at the maxillary first molar area; frequently superimposed on the roots of it

Normal Landmarks Periapical Radiographs

The Maxilla
6. Coronoid Process

Fingerlike projection seen when the second molar region is radiographed

Normal Landmarks Periapical Radiographs

The Maxilla
7. Hamulus

Small projection of bone posterior to the maxillary tuberosity on radiographs of the second molar region

Normal Landmarks Periapical Radiographs

The Maxilla
8. Confusing Areas

Maxillary sinus mistaken for cystic area

Incisive Fossa mistaken for a rarefied area about the lateral incisor root apex

Incisive foramen (if large) suggest the presence of incisive canal cyst or bone refraction if superimposed on the apex of the incisor

Normal Landmarks Periapical Radiographs

The Mandible
1. Lingual Foramen

A small dot inferior to the apices of the central incisors; 0.5 mm radiolucent center lined with radiopaque border

Normal Landmarks Periapical Radiographs

The Mandible
2. Genial Tubercles

Sharp radiopaque projections from the lingual cortical plate of bone

Normal Landmarks Periapical Radiographs

The Mandible
3. Mental Foramen

Radiolucent area licated near the apices of the mandibular bicuspids; multiple foramina may also occur

Normal Landmarks Periapical Radiographs

The Mandible
4. Mental Ridge

Definite linear structures that appears an inverted Vshaped radiopacity and may be superimposed on incisor roots

Normal Landmarks Periapical Radiographs

The Mandible
5. Submaxillary Fossa

Radiolucent area beneath the mandibular molar roots; occupied by the submaxillary salivary gland

Normal Landmarks Periapical Radiographs

The Mandible
6. Mandubular Canal

Horizontal linear radiolucent band bordered by two radiopaque lines beneath the first, second and third molar roots

Normal Landmarks Periapical Radiographs

The Mandible
7. External Oblique Ridge

Radiopaque linear structure immediately superior to the mandibular canal

Normal Landmarks Periapical Radiographs

The Mandible
8. Confusing Areas

Submaxillary Gland Fossa mistaken for a bone rarefaction

Mental Foramen mistaken for a cyst when it is superimposed over the apex of one of the bicuspids

Normal Landmarks Periapical Radiographs

General Landmarks
1. Alveolar process

Trabecular bone that surrounds the roots of the teeth

Normal Landmarks Periapical Radiographs

General Landmarks
2. Alveolar Bone and Crest

Alveolar Bone (Lamina Dura) cortical bone that immediately surrounds the teeth; radiopaque line of uniform thickness

Alveolar Crest most coronal portion of the alveolar process that occupies the space between adjacent teeth; normally within 1 or 1.5 mm above the CEJ

Normal Landmarks Periapical Radiographs

General Landmarks
3. Periodontal Space

Radiolucent line between the root of the tooth and the alveolar bone; represents the space occupied by the periodontal ligament

Complete Mouth Radiographs

Complete Mouth Radiographs

La m i a D u ra co n ti u i a n d n n ty th i ckn e ss
Pathologie s:

C o n ti u o u s l n e a ro u n d th e ro o ts o f th e te e th a n d o ve r th e n i a l o l r cre st ve a B e st se e n i p e ri p i lfi m s n a ca l 2

1.Lack of continuity Active Periodontal Disease 2. Break in the continuity at the apical area inflammatory reaction of the periapical tissue of a nonvital pulp 3. Interruption at the lateral aspect of the root of a tooth extension of periodontal disease 4. Resorption Acute periodontal disease 5. Disappearance with no periodontal pocket or abscess formation on the lateral root surface trauma, lateral root cyst formation or neoplasm

1 4 5

Complete Mouth Radiographs

Pe ri d o n ta lsp a ce s va ri ti n s o a o i w i th n d
S p a ce a ve ra g e s fro m 0 . 1 8 0 . 2 5 m m ( Kronfeld )
Pathologie s:
1.Widening of the crest traumatized tooth from occlusion 2.Excessive widening at the apical region periapical reactions of non vital pulps 3.Widening in the bifurcation and trifurcation of molars advance periodontal disease

C o m p l te M o u th R a d i g ra p h s e o

Level of alveolar crest in relation to the cementoenamel junction

normal level of the alveolar creast is 1 to 1.5mm apical to the cementoenamel junction. The level of the alveolar crest is a very important consideration in the selection of teeth to be retained in periodontal treatment and in the selection of abutment teeth for prosthetic appliances. The terms horizontal and vertical have been applied loosely to the two patterns of bone loss in the reduction of the alveolar crest.

C o m p l te M o u th R a d i g ra p h s e o

Periapical Radiolucency
A periapical radiolucency usually indicates a nonvital tooth. Periapical radiolucencies may be the result of a chronic periapical granuloma, radicular cyst, periapical abscess, or neoplasm.

C o m p l te M o u th R a d i g ra p h s e o

Pathologic conditions of the teeth.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Calcification of the Pulp

occurs for the most part in the incisor and cuspid teeth. In most cases, trauma is involved.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Pulp Stones
Pulp stones are frequently seen in various places in the pulp. Pulp stones, as well as the amount of secondary dentin that can be seen radiographically in the pulp canals, are of importance when a tooth is being evaluated for root canal therapy.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Caries
most common pathologic change seen radiographically in the teeth.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Attrition
Occlusal attrition may be confused with extensive caries in the radiograph.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Calculus
projections near the proximocervical aspect of the tooth or as a linear radiopaque line running from the mesial to the distal aspect of the tooth and representing the buccal or lingual aspect, Calculus that has been altered in contour with a scaler but incompletely removed loses its angular apprearance radiographically ang appreas as a somewhat rounded elevation along the root surface of the tooth.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Conditions caused by overhanging restorations.

Easy to detect in the radiograph when the filling material is radiopaque. Buccal/lingual overhanging are difficult to detect radiographically .

Pa th o l g i C o n d i o n s o f Te e th o c ti

Resorption
Internal/external When resorption has occurred to a somewhat advanced degree at the apex, it may give the impression that the apical portion of the tootht has been cut off.

Root resorption that occurs in an area where the periodontal membrane is intact is almost always caused by trauma of some type from occlusion, othodontic treatment, or prosthetic abutment overload.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Internal Resorption
Internal resorption less frequent that external resorption. Always occurs somewhere along the pulp canal or adjacent to the pulp chamber. radiolucency and maybe confused with dental caries if the the coronal pulp is involved.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Hypercementosis
Excessive cementum deposition on the roots of the teeth. Easily detected radiographically

Pa th o l g i C o n d i o n s o f Te e th o c ti

Dilaceration
Angular curvature of the roots Readily detected on periapical radiographs. Common area: apical third of the maxillary lateral incisors. Important consideration in the diagnosis of teeth that require endodontic treatment or extraction.

Pa th o l g i C o n d i o n s o f Te e th o c ti

Abnormalities of Root Form

Important considerations in the Selection of the abutment teeth for dental prosthesis. Root form and length Number of roots on teeth Portion of the root supported by bone discernible by on properly taken periapical radiographs

Important considerations in Endodontic Treatment The degree of calcification of the radicular portion of the pulp canal. The degree of curvature of the pulp canal. The number of pulp canals present

C o m p l te M o u th R a d i g ra p h s e o

Pathologic Condition of the Jaws

Pa th o l g i C o n d i o n s o f J w s o c ti a

Osseous radiolucencies The ff. should consider:

1. Location and extent of the radiolucency in reference of the teeth,normal landmarks,and anatomic region -it is important to note wether a radiolucent zone is associated with an area from which teeth has been extracted or are congenitally absent. Certain pathologic conditions of the jaws have tendency to occur in in a certain area of either jaw or one jaw in particular. -extremely important in considering the type of treatment and the prognosis 2. Relative degree of radioluscency -depends upon the nature of the pathologic process 3. Presence or absence of radiopaque areas or lines in the substance of the lesion - ossification center or sequestra. 4 The nature of the borders of a lesion -radiolucency relates in some degree of the growth characteristics of certain lesions of the jaws.

4 The nature of the borders of a lesion -radiolucency relates in some degree of the growth characteristics of certain lesions of the jaws.

5.

6.

Apparent effect of the process that is producing radioluscency on the teeth and the anatomic landmarks. -that cause root resorptionof the teeth adjacent to,or involved in the process. Effects on landmarks such asobliteration of normal detail or expansion of normal boundaries of the jaws must also considered as evidence of pathologic proce of an extensive and serious nature Possible origin of the lesion - determine from its location and general characteristics.

Complete Mouth Radiographs

I.

A.Osteolystic lesion CYST - are ostoelystic lesion that they destroy bone by expansion
vary in sized. - very radiolucent,limited buccolingual spaces in the jaws usually little or no normal trabecular pattern superimposed of the cyst.the central portion may shows signs of septal separation of locules or compartments. -Cyst other than radicular arise from residual epithelium lines of fusion of the jaws and are known as fissural cyst.

Nasopalatine cyst

Residual cyst

Complete Mouth Radiographs

A.Osteolystic lesion

II.

Neoplasm a. Benign 1. Odontogenic neoplasm- those do not have the ability to form calcified tissue Ameloblastoma-usually arise in the mandibular third molar

2. Non-odontogenicneoplasm- their general characteristic may be similar to those attributed to a multilocular cystic lesion or a soft odontogenic tumor.

Complete Mouth Radiographs

b. Malignant 1. primary malignant neoplasm - rapid growth and their abilty to invade surrounding tissue and become wide spread. Arise from connective tissue. - the primary radiolucent leion are usually fibrosarcoma and multiple myeloma Fibrosarcoma- widespread or diffuse involvement. Often punched-out 2. Secondary - involve by local invasion or by metastasis, epithelial origin

A.Osteolystic lesion

3. Endocrinopathic bone dysplasia - seen in endocrine dysfunction result of Hyperparathyroidism.

Histologic findings must be supported

Complete Mouth Radiographs

B. Systemic disease -produce radiolucency include eosinophilic granuloma and Hand-Cristian disease. -the radiolucencent zone is not trabeculated and show some angularity of the outline. Often teeth are involve and radiographically lost of bony support. -Hand-SchllerChristian diease involve developing teeth, resulting and destruction malformation of the follicle

Complete Mouth Radiographs

C. Osteomyelitis -suppurative inflammatory process,accompanied by changes in radiolucency in its earlier stages while destroyed. - bone appears to be mothened, and zones of radiolucency surround islands of necrotic bone or sequestra. -later stages show new bone formation with areas of destruction.

D. Residual postoperative osseous defect -seen after extraction of mandibular third molars. - incomplete repair of osseous defect in the maxilla result round radiolucent area that is well defined and surrounded by normal bone.

Complete Mouth Radiographs II. Osseous Radiopacities ff. should be consider in evaluating radiopacities 1. Location and extent 2. relative degree of radiopacity 3. Variations in radiopacity within the lesion 4. Nature of the area immediately surrounding the radiopacity and 5. Possible origin of the lesion A. Tumors 1. Odontogenic -hard odontomas.itis produce by a calcified mass made up of enamel,dentin,and cementum. -relative degree is variable throughout the mass. The enamel in the mass is more radiopaquethan the dentin or cementum - degree of involvement varies from 1cm.

Complete Mouth Radiographs

Enamel pearl- misplaced spherical masses of enamel that appear at the cervical areas of teeth especially in the trifurcation and bifurcation areas of molars. pearls are same degree of radiopacity and relatively greater opacity to dentin and cementum. Cementoma- irregular radiopaque mass involving the apex of one or more teeth.

C o m p l te M o u th R a d i g ra p h s e o 2. Non-odontogenic 1.Bone whorls-islands of compact bone reffered to clerotic bone or bonescars. Irregular outline and clear cut margins. 2.Enostoses- inward growth, similar to bone whorls Exostoses- outwards overgrowths of bone include toriin the mandible and maxilla. Appears increased radiopacitysuperimposed on the roots of the mandibularpre-molars.

C o m p l te M o u th R a d i g ra p h s e o

B. Foreign bodies 1. Root tips- root tips usually associated with edentulou area. May or may not suroundedby thin radiolucent line comparable to the periodontal sp ace. 2. Metallic objects- as result of frequent accidental deposition of amalgam in a extraction socket. 3. Silver amalgam fragmentsappear a small granular radiopaque deposits or large angular pieces.

C o m p l te M o u th R a d i g ra p h s e o
C. Bone dyplasia Include Leontiasis osea and osteopetrosis Generalized radiopacity of the jaws- generalized obliteration of the marrow spaces by osteosclerosisshould suggest to the examiner a generalized bone dysplasia such as leonista osea and osteopetrosis.

III. Combination Osseous radiolucency and radiopacity 1. Location and extent 2. relative degree of radiolucency 3. relative degree of radiopaque 4. variations in the radiopacity within the radiopaque part of the area in question 5. nature of the borders of the areas in question 6. apparent effect of the lesion on the teeth and anatomic landmarks 7. possible origin of the lesion

C o m p l te M o u th R a d i g ra p h s e o
A. Neoplasm 1. Benign a.Odontogenic b.Non-odontogenic 2. Malignant- primary B. Bone dysplasia -that cause a combination of RO & RL are generalized process Pagets diease or oteites deformans generalized process that may affect the jaw in its involvementof the bones of the head . Usually descrbed as cotton wool

Bone enlargement, hypercementosis and resorptiom of teeth may seen if jaw is involve

C o m p l te M o u th R a d i g ra p h s e o

Fibrous dysplasia- characterized radiographically only by a change In trabecular pattern

C. Osteomyelitis D. Foreign bodies IV. Other dental findings impacted teeth, supernumerary teeth, root canal fillings

POSTERIOR BITE-WING RADIOGRAPHS

Po ste ri r B i w i g o te n R a d i g ra p h s o
are used to: 1. determine the continuity of the lamina dura at the alveolar crest - it is less difficult in posterior bitewing radiographs than periapical radiographs - recognition of early periodontal disease is aided by careful inspection of the lamina dura 2. estimate the alveolar crest level in relation to CEJ

Po ste ri r B i w i g R a d i g ra p h s o te n o

3. evaluate tooth crown shape and formative defects of the crown - the level and the vertical lenght of the contact or the lack of a contact between two adjacent posterior teeth are detemined through bitewing radiograph - local formative defects such as hypoplastic pits and alteration of crown form can be seen readily

Po ste ri r B i w i g R a d i g ra p h s o te n o

4. determine pulp size and degree of calcification -pulp size determines thetype of restoration that can be placed in a tooth - degree of pulpal calcificattion representsd the response of the pulp to occlusal functions, restorations, and dental caries

Po ste ri r B i w i g R a d i g ra p h s o te n o

5. evaluate existing restorations -marginal fit, recurrence of dental caries, adequacy of contact points, and depth involvement are important factors in examining restorations.

Po ste ri r B i w i g R a d i g ra p h s o te n o

6. locate calculus - interproximal subgingival calculus appears as spurlike projection on the proximal surface of a tooth - buccal or lingual surface calculus has linear appearance - but not all calculus can be seen radigraphically, bitewing is just supplemental

Po ste ri r B i w i g R a d i g ra p h s o te n o

7. locate carious lesions

- interproximal carious lesions that have progressed through the enamel to involve the DEJ are best viewed through bitewing radiograph - recurrent caries are may be detected more readily - should be inspected in a routine manner, the maxillary teeth should be thoroughly inspected in sequence, followed by mandibular teeth

SUPPLEMENTAL RADIOGRAPHS

S u p p l m e n ta lR a d i g ra p h s e o

Indications: - suspected bone fracture - salivary calculus is suspected - extent of radiographic lesioncannot be determined by means periapical radiographs - the exact location of a radiographic lesion, foreign body, or tooth cannot be determined from periapical radiographs - the patient is unable to tolerate intraoral films - suspicion of TMJ changes

S u p p l m e n ta lR a d i g ra p h s e o

Types: 1. Occlusal films a. Max. and Man. topographic occlusal views b. Max. and Man. anterior occlusal views c. Max. posterior occlusal views

2. Lateral films of the body of the mandible 3. Lateral film of the condyle 4. Temporomandibular joint films 5. Panographic films

S u p p l m e n ta lR a d i g ra p h s e o

S u p p l m e n ta lR a d i g ra p h s e o

R a d i g ra p h s fo r C h i d re n o l
The basic requirement for children is posterior bitewing radiograph, supplemented by lateral films of the jaw and anterior radiographs. Interpratation of radiographs require additional concern that the permanent tooth buds are present.

D a n g e rs Fro m R a d i ti n a o
Hazards to the patient. It is well established that the routine dental radiographs taken from diagnostic purposes do not endanger the patient, when a properly filtered x-ray machine, a diaphragm to limit the size of the x-ray beam and fast x-ray film are used.

D a n g e rs fro m R a d i ti n a o

Hazards to the dentist. Dentists are subject to exposure in varying quantities of radiation. Adequate protection from exposure is easily obtained by proper shielding and properr use of x-ray machine. Whenever possible, a lead-lined shield should be installed in the office, behind this the dentist is completely protected