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Radiographs in endodontic diagnosis

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Radiographs in endodontic diagnosis

  1. 1. RADIOGRAPHIC INTERPRETATIONS IN ENDODONTIC DIAGNOSIS Liya Alice Thomas
  2. 2. CONTENTS Introduction History Terminology Radiographic techniques Interpretation of dental caries Interpretation of trauma, pulpal & periapical lesions Interpretation of restorations & dental materials Interpretation of root canal anatomy Conclusion References
  3. 3. INTRODUCTION
  4. 4. HISTORY •Feb 1895 – discovery of cathode rays by Prof. Wilhelm Roentgen •14 days later – Dr.Otto Walkoff took the first dental X-ray in his own mouth •3 months later – Dr.C. Edmund Kells installed the first X-ray machine in his clinic •1899 – Dr. C.Edmund Kells used X-rays for working length determination (FATHER OF DENTAL RADIOLOGY) •1900 – Dr. Weston Price used radiographs to detect inadequately filled root canals. developed bisecting angle technique.
  5. 5. TERMINOLOGY •IMAGE INTERPRETATION – An explanation of what is viewed on a dental image <or> the ability to read what is revealed by a dental image •DIAGNOSIS – The identification of a disease by examination or analysis
  6. 6. APPLICATION OF RADIOGRAPHY IN ENDODONTICS1. Diagnosis of hard tissue alterations of teeth & periradicular structures 2. Determine the number,location,shape,size & direction of roots & root canals 3. Estimate & confirm length of canals 4. Localize hard-to-find pulp canals by examining the position of an instrument within the root 5. Determine relative position of structures in the facial-lingual dimension 6. Confirm position & adaptation of master cones 7. Aid in evaluation of obturation 8. Facilitate the examination of soft tissues for tooth fragments & other foreign bodies following trauma 9. Evaluate, in follow up films, the outcome of treatment
  7. 7. LIMITATIONS OF RADIOGRAPHS1. Can be easily distorted through improper technique, anatomic limitations or processing errors 2. Buccal-lingual dimension is absent on a single film 3. Various states of pulpal pathosis are indistingushable.Neither healthy nor necrotic pulps cast an unusual image 4. The bacterial status of hard or soft tissue is not detectable-microbiological inference 5. Periradicular soft tissue lesions cannot be diagnosed accurately-histological inference 6. C/c inflammatory tissue cannot be distinguished from healed, fibrous scar tissue Goldman M,Pearson A,Darzenta N.Endodontic success-who’s reading the radiograph? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1972;23:432
  8. 8. TYPES OF IMAGING TECHNIQUES CONVENTIONAL SPECIALIZED 1. Intraoral periapical radiograph 2. Bitewing radiographs 3. Occlusal radiographs 1. Tomography a)Conventional b)Computed c)Three dimensional 2. Scanography 3. Stereoscopy 4. Magnetic resonance imaging 5. Digital subtraction radiography 6. Digital radiography 7. Xeroradiography 8. CBCT
  9. 9. INTRAORAL PERIAPICAL RADIOGRAPH A periapical X-ray is a specific type of intraoral X-ray that is used to investigate the structural integrity of an individual tooth. A periapical X-ray provides an image of a tooth from the tooth’s crown to the tip of its root. Periapical X-rays provide a more highly focused, finely detailed image than the bitewing radiograph CONVENTIONAL RADIOGRAPHS
  10. 10. BITEWING RADIOGRAPH They show the crowns of maxillary and mandibular teeth along with the alveolar crests Mainly used in the detection of proximal caries and to check the cervical margins of restorations
  11. 11. OCCLUSAL RADIOGRAPHS designed to provide a more extensive view of the maxilla and mandible. USES : 1.determining the buccolingual extension of pathologic conditions 2.provides additional information as to the extent and displacement of fractures of the mandible and maxilla.  3.localizing unerupted teeth, retained roots, foreign bodies, and calculi in the submandibular and sublingual salivary glands and ducts
  12. 12. SPECIALIZED RADIOGRAPHS CONVENTIONAL TOMOGRAPHY Synchronized movement of the film & tube in opposite directions about a fulcrum ( ie the plane of interest in the patient’s body) Objects close to the film are clear.objects further away are blurred USES : 1.Precise evaluation of sinus pathologies 2.Used to study facial fractures 3.Evaluation of dental implants 4.In diseases of the TMJ
  13. 13. COMPUTED TOMOGRAPHY Uses x-rays to produce sectional images but the radiographic film is replaced by sensitive crystal or gas detectors which measure the intensity of x-ray beam and convert it into digital data USES : 1)Assessment of maxillofacial fractures and tumors 2)Assessment of TMJ 3)Detecting salivary gland pathosis 4)Preoperative assessment of alveolar bone height & thickness before placing implants
  14. 14. THREE DIMENSIONAL CT Computer program that reformats the acquired data from axial CT scans and converts it into a three dimensional image USES: 1)Craniofacial reconstructive surgery 2)Evaluation of maxillofacial tumors 3)Proper implant design & placement
  15. 15. CONE BEAM COMPUTED TOMOGRAPHY •more efficient and economical than either conventional tomography or computed tomography •CBCT uses a round or rectangular cone shaped x ray beam centered on a 2-dimentional x ray sensor to scan a 360 degree rotation about the patients head •The radiation dose delivered to the patient as a result of one CBCT IS 20% LESS that of conventional CT scan Comparison of periapical radiography with cone beam computed tomography in the diagnosis of vertical root fractures in teeth with metallic post Journal of conservative dentistry Year : 2014 Volume : 17 Issue : 3 Page : 225-229
  16. 16. Comparison of periapical radiography with cone beam computed tomography in the diagnosis of vertical root fractures in teeth with metallic post Aim: To compare the diagnostic accuracy of conventional periapical radiography and cone beam computed tomography (CBCT) in detecting vertical root fracture (VRF) in tooth with metallic post (MP). Materials and Methods: Twenty endodontically-treated teeth received MPs, artificial fractures were created in 10 teeth, and they were all examined with tomography and radiography. The sample consisted of periapical radiography with post and without post, and tomography with post and without post; each group with five fractured and five non- fractured teeth. The images were evaluated by three dental/maxillofacial radiologists and statistical validations were carried out using receiver operating characteristic (ROC) analysis.  Results: Sensitivity and specificity of the area under the ROC (Az) of tomography with post (Az = 0.953) and without post (Az = 0.956) were significantly higher than those of periapical radiography with post (Az = 0.753) and without post (Az = 0.778).  Conclusion: CBCT was more accurate than conventional periapical radiography in detecting VRF.
  17. 17. SCANOGRAPHY  Uses a narrowly collimated fan shaped beam of radiation to scan an area of interest sequentially projecting image data relative to this area onto a moving film  Higher contrast & better details
  18. 18. STEREOGRAPHY Requires the exposure of two films one for each eye as the tube is shifted to 10% of focal film distance Then they are viewed with stereoscope that uses either mirrors or prisms to coordinate the accommodation USES : 1.Evaluation of bony pockets in periodontal diseases 2.TMJ evaluation 3.Status of dental implants 4.Root configurations
  19. 19. Stereographic assessment vs.clinical assessment of mandibularcanal in relation to the roots of impacted lowerthird molar The position of the mandibular canal in relation to the superimposed roots of 173 impacted lower 3rd molars was evaluated radiologically. Stereography technique recently developed for oral radiography was applied in this study. The mandibular canal was located buccally to the roots of 105 (61%) teeth, lingually to the roots of 57 (33%) teeth, and between the roots of 6 (3%) teeth. The relationship of canal to roots of 5 (3%) teeth was not possible to determine. Disagreement between radiological assessment and clinical observation was found in 4 (5%) of 80 operated teeth. The canal was visible at operation in 23 (29%) cases, which was predicted at stereographic examination in 21(91%) cases. The stereographic technique is a useful method with high sensitivity (0.83) for evaluating the bucco-lingual relationship of the mandibular canal to the roots of a 3rd molar. International Journal of Oral and Maxillofacial Surgery Volume 21, Issue 2, April 1992, Pages
  20. 20. MAGNETIC RESONANCE IMAGING • Relies on the phenomenon of nuclear magnetic resonance to produce a signal that can be used to construct an image • Uses nonionizing radiation • USES : 1. Assessment of intracanal lesions 2. Tumor staging in salivary glands,pharynx & larynx 3. Investigations of TMJ
  21. 21. XERORADIOGRAPHY • Based on an electrostatic process similar to that used for Xeroxing • Image is captured on an aluminium plate coated with selenium particles • The various features that make it an attractive diagnostic aid are- 1.Better edge enhancement 2.High contast 3.Positive & negative displays • USES : 1. Determine height of alveolar ridge 2. Detection of caries 3. endodontics
  22. 22. DIRECT DIGITAL RADIOGRAPHY In this digital image is formed which is represented by spatially distributed set of discrete sensors & pixels PHOSPHOR IMAGING SYSTEM :- •Image is captured on a phosphor plate as analogue information & converted into digital format when plate is processed
  23. 23. RVG :-
  24. 24. DIRECT SUBTRACTION RADIOGRAPHY • Images which are not of diagnostic value in a radiograph are reduced so that the changes in the radiograph can be detected. • two standardized radiographs are produced.first-REFERENCE IMAGE & the second is taken for comparison after a period of time. • Both images are superimposed and difference is detected • USES : 1.Assess progression/regression Subtraction radiography. The image to the right is the result of the subtraction of the second image from the first image. Note the dark area indicating bone loss (red arrow) that was not visible on the original image.
  25. 25. INTERPRETATION OF DENTAL CARIES Cariosus (LATIN) - rottenness
  26. 26. CLASSIFICATION OF CARIES ON DENTAL RADIOGRAPHS INTERPROXIMAL CARIES
  27. 27. INCIPIENT INTERPROXIMAL CARIES MODERATE INTERPROXIMAL CARIES ADVANCED INTERPROXIMAL CARIES SEVERE INTERPROXIMAL CARIES
  28. 28. OCCLUSAL CARIES INCIPIENT CARIES MODERATE CARIES SEVERE CARIES
  29. 29. BUCCAL & LINGUAL CARIES ROOT SURFACE CARIES
  30. 30. CERVICAL BURNOUT  Root configuration  Shape of cemento- enamel junction  Exposure factors
  31. 31. MACH BANDS • Mach bands is an optical illusion • Exaggerates the differences between neighbouring areas of slightly differing shades of gray along the boundaries, thus enhancing edge- detection by the human visual system. • A false-positive radiological diagnosis of dental caries can easily arise if the practitioner does not take into account the likelihood of this illusion. Not only do Mach bands manifest adjacent to metal restorations or appliances, but they can also present at the boundary between enamel and dentin . •  Mach bands may also result in the misdiagnosis of horizontal root fractures because of the differing radiographic intensities of tooth and bone
  32. 32. RECURRENT CARIES RAMPANT CARIES
  33. 33. INTERPRETATION OF TRAUMA, PULPAL AND PERIAPICAL LESIONS
  34. 34. FRACTURES CROWN FRACTURES TRAUMA Enamel fracture Enamel-dentin fracture Enamel-dentin-pulp fracture
  35. 35. Crown-root fracture without pulpal involvement Crown-root fracture with pulpal involvement
  36. 36. ROOT FRACTURES HORIZONTAL ROOT FRACTURE VERTICAL ROOT FRACTURE A)At one year recall there is no evidence of any radiographic changes which are suggestive of a problem B)Two years later there is widening of the periodontal ligament space & the appearance of a large periapical lesion.the fracture is seen as a space which has developed on the distal side of the filling due to slight separation of the fragments Moule AJ, Kahler B. Diagnosis and management of teeth with vertical root fractures Australian Dental Journal 1999; 44(2): 75-87
  37. 37. ALVEOLAR FRACTURE
  38. 38. LUXATION INTRUSIVE LUXATION EXTRUSIVE LUXATION SUBLUXATION
  39. 39. AVULSION CONCUSSION
  40. 40. RESORPTION PHYSIOLOGIC PATHOLOGIC INTERNAL EXTERNAL Root canal replacement Internal inflammatory External surface resorption External inflammatory Apical replacement
  41. 41. PHYSIOLOGIC RESORPTION
  42. 42. PATHOLOGIC RESORPTION EXTERNAL RESORPTION A ) EXTERNAL SURFACE RESORPTION LEAST DESTRUCTIVE TYPE OF RESORPTION MAIN CAUSE IS TRAUMA NOT SEEN RADIOGRAPHICALLY CAN BE SEEN ONLY HISTOLOGICALLY NOTREATMENT TRANSIENT OR PROGRESSIVE
  43. 43. B ) EXTERNAL INFLAMMATORY RESORPTION MOST COMMON & DESTRUCTIVE ETIOLOGY : 1)Injury orirritation of periodontal tissues 2)Trauma leading to pulp necrosis 3)Excess orthodontic forces 4)Trauma fromocclusion 5)Pressure resorption(cyst,tumors) RADIOGRAPHIC FEATURES : Bowl like radiolucency with ragged irregularareas seen along with loss of tooth structure & bone
  44. 44. CAUSE - •caries extending to the pulp • traumatic intrusive luxation, oravulsion with re- implantation resulting in necrosis of the root canal systemand development of periapical periodontitis/cyst RADIOGRAPHIC CHANGES : •PDL space widens and loss of the surrounding lamina dura occurs. •The apical root surface becomes irregularand ragged at eitherthe mesial ordistal surfaces . •As the apical periodontitis becomes more progressive, the apical root resorption becomes extensive, causing shortening of the apical one third of the involved root
  45. 45. CAUSES : •bacteria fromperiodontal disease • periodontal treatment • trauma •intracoronal bleaching • orthodontics • bruxism RADIOGRAPHICALLY : moth-eaten, irregular radiolucency superimposed overa root canal in the cervical one third with extension to the surface or PDL space
  46. 46. C ) APICAL REPLACEMENT RESORPTION/DENTOALVEOLAR ANKYLOSIS RADIOGRAPHIC APPEARANCE : •Moth eaten appearance with irregularborder •Absence of periodontal ligament space & lamina dura CAUSE : Occurs as a result of complications following avulsion in which periodontal ligament dries & loses its vitality SERIOUS CONDITION-teeth becomes a part of the bone
  47. 47. INTERNAL RESORPTION A) ROOT CANAL REPLACEMENT / METAPLASTIC RESORPTION RADIOGRAPHIC FEATURES : Enlarged canal space Resorption of dentine followed by deposition of hard tissue that resembles bone orcementum CAUSE : Low grade irritation of pulpal tissue
  48. 48. B) INTERNAL INFLAMMATORY RESORPTION RADIOGRAPHIC FEATURES : Round orovoid radiolucent area in the central portion of the tooth – BALLOONING AREA Progressive loss of dentine is present without deposition of hard tissue in the resorption cavity CAUSES : 1)Longstanding injury causing c/c pulp inflammation & circulatory changes 2)Sudden trauma leading to intrapulpal haemorrage-clot- granulation tissue- odontoclast-resorption
  49. 49. PULPAL LESIONS PULPAL SCLEROSIS PULPAL OBLITERATION PULP STONES
  50. 50. PERIAPICAL LESIONS
  51. 51. PERIAPICAL GRANULOMA PERIAPICAL CYST/ RADICULAR CYST PERIAPICAL ABSCESS RADIOLUCENT LESIONS
  52. 52. APICAL PERIODONTITIS Localized inflammation of periodontal ligament in the apical region Main feature-tooth is tender on percussion RADIOGRAPGICALLY – thickening of pdl space Preceeded by SAP or an apical abscess No subjective signs & symptoms RADIOGRAPHICALLY – “smoldering” lesion-periradicular bone resorption SYMPTOMATIC APICAL PERIODONTITIS ASYMPTOMATIC APICAL PERIODONTITIS
  53. 53. • Mental foramen may be directly superimposed over apex of mandibular premolars • Shadows may be shifted far to mesial or distal merely by shifting horizontal angle of cone of the x-ray machine • Nasopalatine foramen may be superimposed on apex of maxillary central incisors. • if radiolucent area in the radiograph is actually a lesion truly associated with tooth periapex, its shadow will remain “attached” to root end
  54. 54. CONDENSING OSTEITIS/ CHRONIC FOCAL SCLEROSING OSTEOMYELITIS SCLEROTIC BONE/ IDIOPATHIC PERIAPICAL OSTEOSCLEROSIS HYPERCEMENTOSIS RADIOPAQUE LESIONS
  55. 55. INTERPRETATION OF RESTORATIONS & DENTAL MATERIALS AMALGAM RESTORATIONS ONE SURFACE AMALGAM RESTORATIONS AMALGAM OVERHANGS AMALGAM FRAGMENTS
  56. 56. GOLD RESTORATIONS GOLD FOIL RESTORATIONS GOLD CROWNS AND BRIDGES
  57. 57. STAINLESS STEEL CROWNS
  58. 58. CAST METAL POST FIBRE POST PREFABRICAT ED TITANIUM POST
  59. 59. PORCELAIN RESTORATIONS ALL – PORCELAIN CROWNS PORCELAIN FUSED TO METAL CROWNS
  60. 60. COMPOSITE RESTORATIONS ACRYLIC RESTORATIONS
  61. 61. BASE MATERIALS ZINC PHOSPHATE(Cemento LS) > CONVENTIONAL GLASS IONOMER(KetacBond) > RESIN MODIFIED GIC(Fugi II LC) > RESIN CEMENT(Rely X ARC) > ENAMEL Radiodensity of base, liner and luting dental materials Clin Oral Invest DOI 10.1007/s00784-005-0030-3
  62. 62. GUTTA PERCHA SILVER POINTS
  63. 63. INTERPRETATION OF ROOT CANAL ANATOMY FAST BREAK Sudden change in radiolucency within a canal; this change in density probably signals the beginning of an additional canal (Slowey) Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg 1974;37:762-72
  64. 64. WALTON’s PROJECTION Simple technique Anatomy of superimposed structures,root & pulp chambers may be well defined TECHNIQUE : 1. vary the horizontal angulation of the central beam (overlapping canals maybe separated) 2. The apply Clark’s rule (SLOB) or Ingle’s MBD rule to identify the canals
  65. 65. TARGET OR BULL’s–EYE PHENOMENON OR SCORPION TOOTH
  66. 66. DENS INVAGINATUS / DENS IN DENTE A developmental anomaly resulting in a deepening orinvagination of the enamel organ into the dental papilla priorto calcification of dental tissues RADIOGRAPHICA LLY – tooth within a tooth appearance
  67. 67. OTHER DEVELOPMENTAL ANOMALIES GEMINATION : Attempt at division of a single tooth germ by an invagination with resultant incomplete formation of two teeth FUSION : Occurs through union of two normally separated tooth germs CONCRESCENCE : form of fusion which occurs after root formation is complete.here teeth are united by cementum only
  68. 68. TAURODONTISM : condition whereby the body of the tooth and pulp chamber is enlarged vertically at the expense of the roots. As a result, the floor of the pulp and the furcation of the tooth is moved apically down the root. AMELOGENESIS IMPERFECTA :  rare abnormal formation of the enamel. due to the malfunction of the proteins in the enamel : ameloblastin ,  enamelin, tuftelin and amelogenin. RADIOGRAPHICALLY – SQUARE shaped crowns with thin layer of enamel  DENTINOGENESIS IMPERFECTA : genetic disorder of tooth development. This condition is a type of dentin dysplasia that causes teeth to be discolored (most often a blue-gray or yellow-brown color) and translucent giving teeth an opalescent sheen. Teeth are also weaker than normal, making them prone to rapid wear, breakage, and loss. These problems can affect both primary (deciduous) teeth and permanent teeth RADIOGRAPHICALLY-constricted cervical portion.SHELL TEETH & pulpal obliteration
  69. 69. REFERENCES Dental radiology, Principles & Techniques – Joen M Iannucci, Laura Howerton Oral Radiology,7th edition – Stuart C White , Michael Pharoah Textbook of dental & maxillofacial radiology – R. Karjodkar Endodontics – Ingle Endodontics-principles & practices- Mahamoud Torabinejad, Richard Walton Shafer’s textbook of oral pathology,6th edition – R.Rajendran Dental Trauma Guide – International association of Dental traumatology Digital Radiography As A Diagnostic Tool In Dentistry-American association of dental maxillofacial radiographic technicians Dental Root Resorption: A Review of the Literature – Compendium - April 2011, Volume 32, Issue 3

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