Radiographs in endodontics


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Introduction to Endodontics
Forth Year

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Radiographs in endodontics

  2. 2. IMPORTANCE OF RADIOGRAPHY IN ENDODONTICS  The evaluation of pathologic lesions of the head and neck routinely involves the use of radiographs in attempting to determine the nature of the disease process  Radiographs are also essential to all phases of endodontic therapy. They help in : • Diagnosis • During various treatment steps and • Evaluation of the success or failure of treatment.
  3. 3. DIAGNOSIS Identifying the Pathosis : The radiographs help in identifying the lesion whether it is  Pulpal  Periapical  Periodontal  Bony lesions
  4. 4. Determining the Root and Pulpal anatomy :  The number of roots/ root canals  Unusual root morphologies  Root curvatures  Canal locations with respect to the pulp chamber  Bifurcations/ trifurcations  Calcifications
  5. 5. Characterizing Normal Structures :  Helps in differentiating the normal from abnormal structures.
  6. 6. TREATMENT 1. Determining Working Lengths 2. Moving superimposed structures: Certain normal anatomic structures may superimpose on the apices of the teeth. Changing the angulations help in separating them.
  7. 7. Locating canals :  Extra canals  Missed canals
  8. 8. Evaluating the Obturation: The radiographs help us to assess the quality of obturation by helping us to evaluate the 1. Length - if the working length has been maintained - overfilling - underfilling 2. Density - the radiopacity of the material 3. Taper of the preparation of the configuration
  9. 9. RECALL / FOLLOW UP • Most of the times the patient does not know the status of the root canal treatment. • In most cases the patient may be asymptomatic. • In such cases only radiographs help in diagnosing the endodontic failures • There may be evidence of development of new lesions : Periapical, Periodontal, Nonendodontic Or evaluation of the healing / progress of the treatment
  11. 11. RADIOGRAPHIC SEQUENCE I. Diagnostic : The number of films used would depend upon the diagnostic difficulty. The first film should give us the basic details about the Caries → Pulpal involvement → Periapical status A properly positioned film should permit the visualization of atleast 3 to 4mm beyond the apex
  12. 12. Angulation: The most accurate radiographs are made using the paralleling technique
  13. 13. Advantages : Less distortion and more clarity Reproducibility of film and cone placement [ using the XCP ]
  14. 14. Reproducibility : ability to take two or more radiographs of a given tooth at different time intervals and producing an image of same/ near to same characteristics. Especially useful in evaluating the healing of large lesions In cases of low palatal vault, exceptionally long roots, or maxillary tori, the paralleling technique is not possible. In such cases the bisecting angle technique is used
  15. 15. II. WORKING FILMS These are the films which are used during the treatment procedure. Not essentially given to the patient for a record These include  Working length radiograph  Master cone  During obturation [ intermediate ]
  16. 16. Exposure and Film Speed  The exposure gradients for the working films are similar to that of the Diagnostic radiographs.  The films should be clear and the apical extent of the image should be same as that for diagnostic films i.e 3-4mm beyond the apex must be shown .  The tip of the roots and the tips of the files/master cones should be easily identified.  The exposure time for the films depends on the speed.  D>E>F
  17. 17. III. Obturation Similar basic principles as those required for diagnostic radiographs. But after obturation it is advisable to take atleast two radiographs at different angulations to visualize any missed canals
  18. 18. Extrusion of obturation material Obturation short of apex
  19. 19. Normal findings in x-rays • Teeth – dentin and enamel have different shades • due to variation in mineralization – radiopacity: enamel > dentin > pulp – cemento-enamel junction should be recognized • Periodontium – lamina dura is a layer of compact bone (i.e., cribriform plate or alveolar bone proper) that lines the tooth socket – periodontal ligament space • thin radiolucent area between root and lamina dura – alveolar crest • bone that extends between the teeth • normal level no more than 1.5 mm from cemento-enamel junction
  20. 20.  The most consistent radiographic feature aiding diagnosis of pulpal and periapical lesions is the continuity and shape of the lamina dura and the width and shape of the PDL space.
  21. 21.  Endodontic lesions must encroach on the junction of the cancellous bone and cortical bone for radiographic detection.  Lesions are larger than they appear radiographically  The cortical plate must have 12.5% volume of bone loss or 7.1% of mineral bone loss to be detected radiographically.
  22. 22. The radiographic description of any lesion can give us indications of:  Tissue of origin  Biological behavior  Prognosis  Treatment concerns  Diagnosis or a Differential Diagnosis
  23. 23. A radiograph helps in describing the lesion’s  Size  Shape  Location  Density  Borders  Effect on adjacent structures
  24. 24. Shape • Regular • Irregular shape
  25. 25. Location  Localized or generalized  Unilateral or bilateral
  26. 26. Relation of the lesion to other structures and anatomic landmarks  If the radiolucency is above the inferior alveolar nerve canal (IAC), the likelihood is greater that it is odontogenic in origin.  If it is below the IAC, it is unlikely to be odontogenic in origin.  If it is within the IAC, the tissue of origin probably is neural or vascular in nature.
  27. 27. Density Radiopaque Radiolucent
  28. 28. Mixed density:
  29. 29. Effect on adjacent structures • Resorption • Displacement [Space occupying lesions displace other structures] • Destruction • Remodeling • Expansion
  30. 30. Displacement of roots Resorption of roots
  31. 31. Remodelling Expansion
  32. 32.  Many anatomic structures and osteolytic lesions can be mistaken for periradicular pathoses.  Among the more commonly misinterpreted anatomic structures are the mental foramen and the incisive foramen.
  33. 33. Initial / immature phase of Periapical cemental dysplasia Mature phase of Periapical cemental dysplasia
  34. 34.  These radiolucencies can be differentiated from pathologic conditions by exposures at different angulations and by pulp-testing procedures.  Radiolucencies not associated with the root apex will move or be projected away from the apex by varying the angulation
  35. 35. • Other anatomic radiolucencies that must be differentiated from periradicular pathoses are  Mental Foramen  Lingual Foramen  Submandibular Fossa  Nutrient Canals  Median Palatal Suture  Incisive Canal Foramen  Nasal Cavity  Mandibular Canal  Maxillary Sinus
  36. 36. Differential diagnosis Endodontic lesions Radiolucent lesions : 1. Apical /radicular lamina dura is absent 2. A hanging drop of oil shape . Though a lesion ca be of any shape 3. Radiolucency stays at the apex regardless of change in the angulation. 4. The cause for pulp necrosis is ,in most cases ,evident
  37. 37. Radiopaque lesions Condensing / sclerosing osteitis
  38. 38. Non odontogenic lesions
  39. 39. (Idiopathic) Osteosclerosis
  40. 40. Special Techniques : Bitewing Projections : Useful in diagnosing dental caries Especially the relation ship of the alveolar bone to the dental caries [ proximal lesions]
  42. 42. A and B, A straight-on view will cause superimposition of the buccal object (yellow circle) with the lingual object (red triangle). C and D, Using the tube-shift technique, the lingual object (red triangle) will appear more mesial with respect to the mesial root of the mandibular first molar, and the buccal object (yellow circle) will appear more distal on a second view projected from the mesial. E and F, The object (red triangle) on the lingual surface will appear more distal with respect to the mesial root of the mandibular first molar, and the object (yellow circle) on the buccal surface will appear more mesial on a view projected from the distal aspect.
  43. 43. Important considerations: Film selection Film Holders Film Placement Cone alignment
  44. 44. Latest Radiographic Devices Digital Radiography
  45. 45. Micro Computed Tomography [Micro CT] Cone beam CT