Radiology in pedodontic practiceGUIDED BY : Presented by:Dr. Neeraj solanki Saadia meraj khanDr.Megha Roll no. 8749074Dr. Piyush
ACKNOWLEDGEMENTI am extremely thankful to all the staff members of theDepartment of Pedodontics throughout our clinicalposting.The immense knowledge and experience ofDr.Neeraj Solanki and his continuous help,support andencouragement has been extremely useful to us.We would like to thank Dr. Piyush and Dr.Megha fortheir skillful and gentle support in the presentation ofcontent.Without their active participation and help thisproject would have been impossible to complete.
INTRODUCTION• Plays a vital role in the diagnosis and treatment planning of both children and adults.• Plays a significant role in the assessment of growth and development.• At the simplest level, help in the detection of dental caries and at the most complex level, in the diagnosis of cysts, tumors or any other major craniofacial disorders.
Points to be considered before planning for radiographs• Avoiding retakes by• Obtaining the previous radiographic history• Following the appropriate guidelines for the correct size, number and type of film used• All area to be radiographed should be included within the film borders, avoiding cone cut, overlapping, elongation, shortening and correctly processing the film.
Contd.• Radiographs should be an adjunct for clinical examination and should not replace full mouth clinical examination.• Determination of appropriate number and size of films required to take radiographs of the particular region and unnecessarily not the whole mouth.• Placement of lead apron and thyroid collar on the patient and parent.
Dental X – Ray machine Dental X-ray machine: A: Positioning Device; B: Tube head; C: Control panel or the timer
Component of IOPA film packetComponents of IOPA film packet: A. Outer plastic wrapper; B. Black paper; C. Film; D. Lead foil
Guidelines for prescribing radiographs• Evaluation of the Development of Dentition• Stages of development, eruption and exfoliation of teeth• Amount of root formation• Physiologic root resorption• Amount of bone over the erupting tooth• Degree of pulp maturity.
Contd.• Pathologic Evaluation• Caries detection• Evaluation of traumatic injuries• Degree of pulp involvement such as proximity of caries to pulp horn, internal resorption or calcific degeneration• Evaluation of periodontal health by observing thickness of periodontal ligament, furcation involvement, bone loss, external resorption etc.
Contd.• Detection of Developmental Anomalies• Widely divergent roots• Sharply curved pulp canals• Alterations in the number and length of roots• Ectopically positioned teeth• Ankylosis• Supernumerary teeth• Congenitally missing teeth• Malformed teeth such as microdontia, macrodontia, dens in dente, taurodontism, gemination, fusion, root dilacerations etc.
Contd.• Post-treatment Evaluation• Accuracy of treatment• Type and success of pulp treatment• Post surgical healing• Treatment failure
Radiographic examinationsFour film series: This series consists of a maxillary and mandibular occlusal radiographs and two posterior bitewing radiographs.
Radiographic examinationsEight film survey:• This survey includes a maxillary and mandibular anterior occlusal radiographs.• Four molar periapical radiographs.• Two posterior bitewings
Radiographic examinationsTwelve film survey:• This survey include maxillary and mandibular permanent incisor periapical radiographs.• Four primary canine periapical radiographs.• Four molar periapical radiographs.• Two posterior bitewing radiographs
Radiographic examinationsSixteen film survey: This examination consists of the twelve-film survey and the addition of four permanent molar radiographs.
Suggested radiographic protocol for the child patient with no previous radiographsAge Consideration Radiograph3-5 No apparent abnormalities (open contacts) None No apparent abnormalities (closed contacts) 2 posterior bite wings, size 0 Extensive caries film Deep caries 4-film survey Selected periapical radiographs in addition to 4-film survey
Contd.Age Consideration Radiograph6-7 No apparent abnormalities 8-film survey (available by 7 years of age) Extensive or deep caries Selected periapical radiographs in addition to 8-film survey
Contd.Age Consideration Radiograph8-9 No apparent abnormalities or extensive or deep 12-film survey caries10-12 No apparent abnormalities or extensive or deep 12 or 16 film survey caries depending upon size
Intraoral film size• Size 0 - Used for bite wing and IOPA of small children• Size 1 - Used for anterior teeth in adults• Size 2 - Standard film, used for anterior occlusal, IOPA and bite wing in mixed and permanent dentition• Occlusal films - 57 x 76mm used for maxillary or mandibular occlusal radiographs
Radiographic techniques commonly used in childrenIntraoral• lOPA• Bite wing• Occlusal• PanoramicExtraoral• TMJ and lateral oblique view (film size is 1.5 x 7inches)• Lateral cephalograms, PNS view (film size is 8 x 10 inches)• Orthopantomography (film size is 6 x 12 inches)
Intraoral Periapical (IOPA) RadiographsIndications:• To evaluate the development of the root end and to study the periapical tissue• To detect alterations in the integrity of the periodontal membrane• To evaluate the prognosis of the pulp treatment by observing the health of the periapical tissues• To identify the stage of development of unerupted teeth• To detect developmental abnormalities like supernumerary, missing or malformed teeth
Contd.Indications:• For early detection of pathologic changes associated with teeth• For space analysis in the mixed dentition• To assess the path of eruption of permanent teeth• To evaluate the extent of traumatic injuries to the root and alveolus
Techniques for taking IOPA• The paralleling technique• The bisecting angle technique
The paralleling technique• The film is positioned in the mouth using extension cone parallel (XCP) instruments or precision film holders such that the film is held parallel to the long axis of the tooth to be radiographed.• The X-ray tube head is aimed at right angles to the tooth and the film.
The paralleling techniqueAdvantage:• Little magnification• Periodontal bone level are well represented• Radiographs are accurately reproducible by different operators
The paralleling techniqueDisadvantage:• Difficult to position the film• May not be possible to place the film in shallow palates
Bisecting angle technique• The film is placed close to the tooth to be radiographed using snap a ray film holder or hemostat• The X-ray tube is adjusted such that the central ray of the X-ray bisects the angle formed between the long axis of the film and the tooth.
Bisecting angle techniqueAdvantage:• Film positioning is easy and comfortable for the patient• If positioned based on correct angulations, the image size does not alter
Bisecting angle techniqueDisadvantage:• Variables are many in this technique making it difficult to reproduce accurately every time.• Incorrect vertical angulation results in elongation of the image and incorrect horizontal angulation results in overlapping of the images of the crown and root or cone cut .• Periodontal bone level are not clear.• Detection of proximal caries is difficult.
Bite Wing RadiographsIndications :• Early detection of incipient interproximal caries• To understand the configuration of the pulp chamber• Record the width of spaces created by premature loss of deciduous teeth• Determine the presence or absence of premolar teeth• To determine the relation of a tooth to the occlusal plane for possibility of tooth Ankylosis
Bite Wing RadiographsIndications:• Detect levels of periodontal bone at the interdental area• Detect secondary caries
Bite Wing RadiographsTechnique:• The head is positioned such that the midsagittal plane is perpendicular and the ala-tragus line is parallel to the floor.• The lower edge of the film is placed in the floor of the mouth between the tongue and the lingual aspect of the mandible and the bite tab is placed on the occlusal surfaces of the mandibular teeth.• The film is positioned to cover all the region of concern.• The central ray enters at the occlusal plane at a point below the pupil, vertical angle being +8 degrees.
Occlusal RadiographIndications:• Determine the presence, shape and position of midline supernumerary teeth• Determine impaction of canines• Determine the presence or absence of incisors• Assess the extent of trauma to teeth and anterior segments of the arches• In case of trismus and trauma, where the patient cannot open the mouth completely• Determine the medial and lateral extent of cysts and tumors.
Anterior maxillary occlusal technique• In the anterior maxillary occlusal technique, the patients occlusal plane should be parallel to the floor and the sagittal plane should be perpendicular to the floor• A No.2 periapical film is placed in the patients mouth so that the long axis of the film runs from left to right rather than anteroposteriorly and the midsagittal plane bisects the film.• The patient is instructed to bite lightly to hold the film.The anterior edge of the film should extend approximately 2 mm in front of the incisal edge of the central incisors.
Contd.• The central ray is directed to the apices of the central incisors and a half inch above the tip of the nose and through the midline. The vertical angle is + 60 degrees.• The film is exposed at the usual setting for maxillary incisor periapical films.
Anterior maxillary occlusal radiograph and technique
Posterior maxillary occlusal technique• In the poste-rior maxillary occlusal technique, the patients occlusal plane should be parallel to the floor, and the sagittal plane should be perpendicular to the floor• A No.2 periapical film is placed in the patients mouth so that the long axis of the film is parallel to the floor.• The anterior edge of the film should extend just mesial to the canine. The outer buccal edge of the film should extend ap-proximately 2 mm beyond the primary molar crowns.
Contd.• The patient is instructed to bite lightly to hold the film. The central ray is directed toward the apices of the primary molars as well as inter-proximally.• The vertical angle is + 50 degrees. The film is exposed at the usual setting for maxillary premolar periapical films.
Anterior mandibular occlusal technique.• The film placement for the anterior mandibular occlusal technique is identical to that for the anterior maxillary occlusal technique, except that• The patients head is positioned so that the occlusal plane is at a – 45 degree angle.• The cone is then aligned at a – 15 degree vertical angle, and the central ray is directed through the symphysis.
Panoramic Radiographs• It is an extra oral radiograph in which the X-ray film and the X-ray source move in opposite directions.• It can be used to visualize the entire dentition.• This reduces the total number of films and thus reduces the radiation exposures.• This can also be used to introduce the child to radiography as it is an extraoral radiograph.
Contd.• It requires a total of 15 to 22 seconds to record.• Although it is considered as a supplement it cannot substitute intraoral radiographs in the diagnosis of caries or for viewing the periapical region.• This view can be useful in handicapped children and for viewing a wide area of the TMJ and associated region.
Special technique for the handicapped child• The physically handicapped child cannot usually hold a film in hisher mouth with fingers.• In such a child radiograph can be taken by the parent holding the child or by the use of film holding devices.• If the child is unable to open the mouth, extra oral radiographs such as panoramic view, lateral jaw projections, anterior occlusal screening, should be preferred.
Management Techniques• One of the most challenging tasks for the clinical staff is to obtain diagnostic quality radiographs on a young patient (under three years of age) without psychological trauma.• The first step is to desensitize the child to the dental experience• By explaining to the child what you plan to do in words easily comprehended by the child.• Using a "tell, show, do" technique.
Contd.• The child is positioned to gain maximum cooperation.• In the child less than three years of age it may be necessary for the child to sit in the parent’s lap while the radiograph is exposed.• Such positioning reduces the child’s anxiety, provides additional emotional security for the child, increases cooperation and also enables the parent to adequately restrain child and avoid any unexpected sudden movements.• Obtaining the least difficult radiograph first (such as an anterior occlusal) desensitizes the child to the procedure.• Correct settings are made on the apparatus and the x-ray head is properly positioned before placing the film in the child’s mouth.
Positioning the Radiograph• Positioning the radiograph vertically in the mouth for both periapical and bitewing radiographs reduces the distal extension of the radiograph and may result in greater tolerance by patients, especially those with a mild gag reflex.• The vertical bitewing radiograph provides greater detail of the periapical area.
Contd.• The Snap-A-Ray is also useful for those patients that have a fear of swallowing the radiograph.• By biting on the large positioning device and watching in a mirror they are assured they will not swallow the radiograph.
Contd.• A self sticking sponge tab may also reduce impingement of the radiograph on the intraoral soft tissue.• For patients frightened of the procedure itself, desensitization techniques may be necessary to gain the patient cooperation.
Desensitization Techniques• Desensitization is defined as gradually exposing the child to new stimuli or experiences of increasing intensity.• An example of this is introducing the patient to x- rays by initially taking an anterior radiograph which is easier to tolerate than a posterior radiograph.
Contd.• Another example of desensitization is the “Lollipop Radiograph Technique.” The child is given a lollipop to lick (preferably sugarless).• After a few licks, the lollipop is taken from the child and a radiograph is attached to the lollipop using an orthodontic rubber band. The lollipop with the attached film is returned to the child, who is told to lick the lollipop again.• After a few licks, the child is told to hold the lollipop in his mouth while we take a tooth picture. The exposure is made.
Probable Technical Errors• Improper placements of films.• Cone cutting• Incorrect horizontal angulations• Incorrect vertical angulations• Over exposure due to defective devices.• A high exposure of the patient to radiation because of repetition of taking X-rays due to an uncooperative child.
Radiation hygiene measures• Proper registration and maintenance of radiographic units• Training of personnel who are associated with radiography• Dosage monitoring• Radiation protection of the child patients by using lead apron with thyroid collar.• Use of long lead-lined cylinder and cone positioning devices• Use of electronically controlled exposure timer• Use of high speed films• Use of automatic processing machines that give good consistent result• Employing proper technique to avoid the chances of repeating exposure.