Radiographic aids in dx of periodontol ds part 2

1. -
Radiographic Aids In Diagnosis of
Periodontal Diseases – Part B

2. CONTENTS
1. Interpretation of an OPG
2. Interpretation in relation to periodontal diseases.
3. Advances in radiographs.
4. Implant imaging (Briefly).
5. Limitations of radiographs.
6. Limiting radiation exposures.
7. Conclusion.
8. References.
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3. Prichards Criteria (1972)
Adequate angulation
1. The radiograph should show the tips of the molar cusps
with little or none of the occlusal surface showing.
2. Enamel caps and pulp chambers should be distinct.
3. Interproximal spaces should be open.
4. Proximal caps should not overlap unless teeth are out of
line anatomically.
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4. Interpretation of an OPG4

5. Orthopantomograph
Panoramic perspective
 Commonly used imaging modality in dental practice.
 Complex projection of the jaws.
 Depicts numerous anatomic structures outside of the jaws.
 Right and left posterior parts of the image represent lateral
views.
 Anterior part of the image represents an
anterior-posterior view.
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6. Orthopantomograph
Osseous Structures
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a. Pterygoid plate
b.Pterygomaxillary
fissure
c. Zygomatic
process of
maxilla
d.Zygomatic arch
e. Temporal
component of
tmj
f. Mastoid process
of temporal bone
(not imaged)
g.Lateral and
inferior orbital
rim
h.Infraorbital canal
i. Inferior concha ⁄
turbinate;
j. Hyoid bone.

7. Orthopantomograph
Osseous Structures
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1. Maxillary sinus
2. Pterygomaxillary
fissure
3. Pterygoid plates
4. Hamulus
8. Zygomatic process
11.Middle cranial fossa
15.Infraorbital canal
16.Nasal fossa
20.Incisive foramen
23.Condyle
24.Coronoid process
26.Medial sigmoid
depression
30.Mandibular canal
31.Mandibular foramen
32.Lingula
34.Submandibular gland
fossa
36.Mental fossa
38.Genial tubercles

8. Orthopantomograph
Osseous Structures
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5. zygomatic arch
6. articular eminence
7. zygomaticotemporal
suture
9. external auditory
meatus
12. lateral border of the
orbit
13. infraorbital ridge
14. infraorbital foramen
17. nasal septum
18. anterior nasal spine
19. inferior concha
22. maxillary tuberosity
25. sigmoid notch
28. cervical vertebrae
33. mental foramen
39. hyoid bone

9. Orthopantomograph
Air/Soft tissue shadows
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10. Orthopantomograph
Ghost images
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11. Orthopantomograph
TMJ Evaluation
 Bony ankyloses –
 Overall obliteration of the joint space.
 Antegonial notching anterior to the angle of mandible.
 Elongation of coronoid process.
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 Bruxism –
 Loss of cartilage & erosion of bone over the condylar head.
 Flattening & widening of the articular eminence
 Elongation of coronoid process.

12. Orthopantomograph
OPG Interpretation
1. Assess the periphery and corners of the image –
 Orbits.
 Articular processes of the temporal bones (at theTMJ).
 Cervical spine.
 Styloid processes.
 Pharynx.
 Hyoid bone.
2. Examine the outer cortices of the mandible –
 Anterior and posterior rami.
 Coronoid processes.
 Condyles and condylar necks.
 Inferior border.
3. Examine the cortices of the maxilla –
 Zygomatic process of the maxilla.
 Pterygomaxillary fissure.
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13. Orthopantomograph
OPG Interpretation
4. Examine the zygomatic bones and arches –
5. Assess the internal density of the maxillary sinuses –
 Compare left and right sides.
6. Assess the structures of the nasal cavity and the palates –
 The nasal floor ⁄ hard palate and conchae.
 The nasal septum in the midline.
 The soft palate seen bilaterally.
7. Examine bone the pattern of the maxilla and mandible–
 Assess the density and pattern of the trabeculae for
abnormalities.
 In the mandible examine the size, position, cortication and
symmetry of the:
– inferior alveolar nerve canals.
– mandibular foramina.
– mental foramina.
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14. Orthopantomograph
OPG Interpretation
8. Alveolar processes and teeth–
 Assess the crestal bone position of the alveolar processes
to identify any periodontal bone loss.
 Examine the periodontal ligament space and lamina dura
around each tooth for signs of inflammatory disease.
 Examine the follicles and papillae of developing teeth for
anything affecting their size, position or cortical
boundaries.
 Evaluate the teeth for presence⁄ absence ⁄ eruptive or
positional abnormalities, caries, inadequate restorations,
calculus, developmental or acquired abnormalities.
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15. Interpretation in relation to
periodontal diseases.

16. Periodontal Diseases
Severity of periodontal bone loss
 Early bone loss
ranges from slight blunting,
loss of cortex, decreased
density or a less defined or
irregular appearance of the
alveolar crests, to bone loss
of up to 1 mm.
 Moderate bone loss
ranges from 1 mm of
periodontal bone loss up to
the mid-root point.
 Severe bone loss
Extends beyond the mid-
root or the bony defect
involves a furcation.
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17. Periodontal Diseases
Goodson et al. 1984
 Should be recognized that radiologically detectable periodontal bone
loss is preceded by clinically detectable inflammatory periodontal
disease.
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Mann et al. 1985; Khocht et al. 1996
 The limitations of the radiographic examination of periodontal bone
loss, especially intraoral and panoramic radiography, must be
recognized and correlation with clinical findings is important

18. Morphology of Periodontal Bone Loss
Horizontal bone loss
 Bone loss is parallel with the cementoenamel junction (CEJ), usually
involving multiple teeth.
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19. Morphology of Periodontal Bone Loss
Angular/Vertical defects
 The bone loss is uneven and oblique, centered upon one tooth more
than the adjacent tooth
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20. Morphology of Periodontal Bone Loss
Interdental crater defects
 It is often not appreciated on plain 2D imaging, but may appear as a
focal hypodense region at the superior aspect of the interdental bone.
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21. Morphology of Periodontal Bone Loss
Infrabony defects
 These refer to focal bone loss which
extends along a root surface apically.
These defects can be:
 Three‐walled, where both buccal and
lingual cortices are preserved.
 Two‐walled, where a buccal or lingual
cortex is effaced.
 Single‐walled, where both buccal and
lingual cortices are effaced.
 A Single‐walled defect appears lucent and
well defined, whereas a Three‐walled
defect appears hypodense rather than
completely lucent with borders that can
appear less well defined. 21
Single-Walled

22. Morphology of Periodontal Bone Loss
Infrabony defects
22
Two-Walled
Three-Walled

23. 23
Two-Walled
Three-Walled
One-Walled

24. Morphology of Periodontal Bone Loss
Infrabony defects
 Presence & appreciation of periodontal defects morphology, including
vertical defects, is best appreciated with volumetric imaging
techniques, including MCT and CBCT (Langen et al. 1995; Fuhrmann
et al. 1995, 1997; Mengel et al. 2005; Misch et al. 2006; Mol &
Balasundaram 2008;Vandenberghe et al. 2008)
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25. Morphology of Periodontal Bone Loss
Furcation defects
 Early inflammatory disease involvement of a furcation usually presents
radiologically as a widened periodontal ligament space at the
furcation.
 On plain 2D imaging, lucent and relatively welldefined mandibular
molar furcations are usually only seen when there is destruction of
either the buccal or lingual cortical plates, or both.
 If both or one of cortices are preserved, the mandibular molar furcation
defect appears as a focal region of varying hypodensity and definition.
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26. Morphology of Periodontal Bone Loss
Furcation defects
 2D radiographic examination for furcation defects is limited, especially
of the maxillary molars, largely because of the presence of the palatal
root.
 Classically described “J‐shaped” lucent appearance is sometimes seen.
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27. Morphology of Periodontal Bone Loss
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28. Morphology of Periodontal Bone Loss
Furcation defects
 It should also be noted that an inflammatory furcation lesion may also
be of pulpal origin, related to accessory pulpal canals, root resorption
or iatrogenic perforation.
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29. Morphology of Periodontal Bone Loss
Perio-endo defects
 These are lucent lesions extending
from the crestal bone to the apex of
a tooth root, but are not always
clearly apparent on plain 2D
imaging.
 Radiologically, it can be difficult to
distinguish between the various
causes, although the morphology of
the lesion may provide useful clues
which can be correlated with the
clinical findings.
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30. Morphology of Periodontal Bone Loss
Trauma from occlusion
 Injury phase of TFO produces
loss of the lamina dura that may
be noted in apices, furcations &
marginal areas – resulting in
widening of the PDL space.
 Repair phase of trauma from
occlusion results in an attempt
to strengthen the periodontal
structures to better support the
increased loads – generalised or
localised widening of the PDL,
space.
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31. Advances in Radiographs31

32. Computer Assisted Densitometric Image Analysis
System (CADIA)
Urs Brägger et al 1988
 A video camera mesaures the light transmitted through the a
radiograph
 Signal are converted to grey scale images
 Camera is interfaced with computer and image processor for
storage and mathematic manipulation of image
 Offers an objective method for studying alveolar bone changes
quantitatively
 High degree of sensitivity ,accuracy and reproducibility .
 More sensitive than subtraction radiography. 32

33. Computer-BasedThermal Imaging
ProbeyeThermal Imaging Systems
 Compare the rewarming rates of normal
and inflamed human gingiva.
 Gingival temperature measurement.
 Infra-red thermography provides a non-
invasive method.
 Technique is no more in use.
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34. Computer-BasedThermal Imaging
ProbeyeThermal Imaging Systems
34

35. Computer Software programmes
Denta Scan, i CatVision, Carestream 3D Imaging, Simplant
 Provides computed tomographic (CT) imaging of the mandible and
maxilla in three planes of reference: axial, panoramic, and oblique
sagittal.
 Assessment of bone volume, bone height & quality.
 Proper length of implant can be selected.
 Clear visualization of inferior alveolar canal.
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36. Digital tomosynthesis (DTS)
 Digital tomosynthesis (DTS)
is a limited-angle
tomographic technique.
 Only small rotation angles (a
few tens of degrees) with a
small number of discrete
exposures are used.
 Provides some of the
tomographic benefits of
computed tomography (CT).
 At reduced dose and cost.
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K Ogawa et al 2010

37. Digital tomosynthesis (DTS)
 Proposed the use of both DTS and CBCT reconstruction methods
as an integrated solution for providing tomographic data in dental
application.
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C Beda in 2010

38. Optical CoherenceTomography
 Optical coherence tomography
(OCT) is an optical signal acquisition
and processing method
 An interferometric technique,
employing near-infrared light.
 OCT is well-suited for periodontal
diagnosis.
 Pocket morphology, and attachment
level are digitally recorded.
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K Ogawa et al 2010

39. Optical CoherenceTomography
 Demonstrate the capacity of OCT to determine gingival thickness
and the shape and contour of the alveolar crest.
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Otis L.L et. al. 2004
 OCT imaging can offer three-dimensional imaging of periodontal
soft tissues and bone at a very high resolution .
 Identify active periodontitis before significant alveolar bone loss
occurs.
 Reliable method for determining attachment level
Xiang et al. 2009

40. TACT-tuned aperture CT
 Based on the principles of tomosynthesis.
 Low cost,low dose ,3D Imaging stystem.
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 Series of radiographs taken
from different angles
 Soft ware (work bench) stacks
the basic images and
reconstruct in to multi planar
images

41. TACT-tuned aperture CT
 Compared the potentials of conventional and TACT DSR detecting
simulated bone-gain in periodontal defects, in vitro
 TACT-DSR provide greater sensitivity and technique flexibility in
detecting periodontal bone-gain than standard DSR.
41
Onanong Chai-U-Dom 2002
 Compared the diagnostic efficacy of tuned-aperture computed
tomography (TACT) and conventional two-dimensional direct
digital radiography (DDR) in an in vitro environment for detecting
bone loss in mid-buccal and lingual crests.
 TACT performed significantly better than DDR
Nair M K et al. 2002

42. SmallVolume CT
 Form of CBCT.
 Utilizes small field high resolution detector to generate high
resolution 3D volume.
 Generally comparable to size of intraoral radiographs.
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 Based on comparison made
between a full CT geometry and a
local CT geometry.
 “local CT of dental structures
appears to be a promising
diagnostic instrument.”
van Daatselaar 2003

43. Implant Imaging43

44. Implant Imaging
 Images should have appropriate diagnostic quality and not contain
artefacts that compromise anatomic-structure assessments.
 Images should extend beyond the immediate area of interest to
include areas that could be affected by implant placements.
 Practitioners should have appropriate training in operating
radiographic equipment and competence in interpreting images
from the modality used.
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Principles of imaging for dental implant assessment

45. Implant Imaging

46. • Panoramic radiography should be
used as an imaging modality.
RECOMMENDATION
1
• Use IOPAs to supplement
panoramic radiography.
RECOMMENDATION
2
• Do not use cross sectional
imaging as an initial diagnostic
aid.
RECOMMENDATION
3
Implant Imaging
1. Initial Examination

47. Implant Imaging
Goal 1
• Establish characteristics of residual alveolar bone.
Goal 2
• Determining orientation of RAR.
Goal 3
• Identifying local conditions restricting implant placement.
Goal 4
• Match imaging findings to the prosthetic plan.
2. Preoperative site specific imaging

48. 2. Preoperative site specific imaging
• CBCT imaging should be
considered if bone reconstruction
and augmentation procedures
(e.g., ridge preservation or bone
grafting) have been performed to
treat bone volume deficiencies
before implant placement.
RECOMMENDATION
7
Implant Imaging

49. 3. Post-operative imaging
• In the absence of clinical signs or symptoms
use IOPAs or OPGs.RECOMMENDATION 8
• Patient has mobility or altered sensation use
cross sectional imaging/CBCT.RECOMMENDATION 9
• Do not use CBCT imaging for periodic review
of clinically asymptomatic implants.
RECOMMENDATION
10
• Implant retrieval - CBCT.RECOMMENDATION
11
Implant Imaging

50. Limitations of Radiographs50

51. Limitations of Radiographs
 More than 30% of bone mass at alveolar crest must be lost to be
recognized on radiographs
 Radiographs provide a 2-dimensional view of a 3-dimensional
situation, provides only information about inter proximal bone
level.
 Radiographs do not demonstrate soft tissue - to - hard tissue
relationship hence no information about depth of soft tissue
pocket.
 Due to superimposition, the details of the bony architecture may
be lost.
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52. Limitations of Radiographs
 Do not record soft tissue contours (Gingivitis is no seen on
radiograph, pockets can not be seen on radiographs).
 Measurement of bone level from CEJ is not valid in supra eruptions
& passive eruptions.
 Interdental craters cannot be identified by radiographs.
 Widening of periodontal ligament does not necessarily mean tooth
mobility.
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53. Limitations of Radiographs
 They cannot successfully distinguish between treated & untreated
cases.
 Furcations cannot be seen properly (e.g. furcation in maxillary
molars are masked by the palatal roots, & it becomes difficult to
evaluate radiographically only ).
 Resorption of lingual or buccal cortical plates cannot be
differentiated by radiographs alone.
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54. Limiting Radiation Exposure54

55. Limiting radiation exposure
 use of the fastest image receptor compatible with the diagnostic
task (F-speed film or digital).
 Collimation of the beam to the size of the receptor whenever
feasible.
 Proper film exposure and processing techniques.
 Use of protective aprons and thyroid collars, when appropriate.
 Limiting the number of images obtained to the minimum
necessary to obtain essential diagnostic information.
55
ADA recommendations 2012

56. Conclusion56

57. Conclusion

58. Conclusion
 Radiography must not be a substitute for clinical investigation
 X-rays should be used as a component of periodic examinations.
 Advanced imaging systems like CTs, CBCTs, have enabled better
visualization of periodontal structures and pathologies in 3D thus
helping in better diagnosis and treatment planning.
 The cost factor and other technical difficulties have limited their
clinical utility but their utility as a research tool is unquestionable.
 And in near future these imaging techniques will become routine
diagnostic tools.
58

59. References
1. Clinical PeriodontologyAnd Implant Dentistry; Jan Lindhe; 6th Edn
2. Oral Radiology-principles And Interpretation; Stuart C. White; 5th
Edn
3. Clinical Periodontology; Newman, Takei, Klokkevold, Carranza; 10th
Edn
4. Radiology In Periodontics – A Review ; J. IndianAcademy Of Oral
Medicine & Radiology; 2013; 25 (1); 24-29.
5. P.F.Van Der Stelt; Modern Radiographic Methods InThe Diagnosis
Of Periodontal Disease;Adv Dent Res 7(2):158-162,August, 1993
6. Bragger U: Digital Imaging In Periodontal Radiography-A Review; J
Clin Periodontol 1988: 15: 551-557
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60. Next Presentation – OnThursday
26/05/2016
Journal Club Presentation By–
1. Dr. Ibrahim Shaikh
2. Dr. Jyotsna Singh
THANK
60