Radiograph Analysis - Orthodontics

1. Radiograph Analysis
Orthodontics
Nasir Al-Hamlan BDS, MPH, MSc, FDS RCSEd, MOrth RCSEd, FICD
Consultant and Assistant Professor, Orthodontics
King Saud bin Abdulaziz University for Health Sciences
NGHA, Riyadh
@nhalhamlan
@saudibraces
nasiralhamlan
@nasiralhamlan

2. Radiographs:
o Panoramic
o Cephalometric (lateral, PA).
o Intra-oral (Periapical, Bitewings).
o CBCT
o Hand Wrist

3. Radiographs:
Pano and ceph always, intraorals if u suspect something or in adults
for perio, CBCT has specific indications! some schools or
practitioners always take it.

4. Panoramic Radiograph

5. Advantages of Panoramic Radiograph:
• Broad coverage of the facial bones of teeth (can visualize both Mx and Md).
• Low radiation dose (<exposure than FMS).
• Convenience for the patient, can be used in patient with Trismus.
• Short time required to produce.
• Good visual aid to explain treatment to patients.

6. Disadvantages of Panoramic RG:
•No fine details like in Intraorals; reduced sharpness (due to increased object-film
distance).
•Proximal surfaces of premolar overlap.
•Uneven magnification and geometric distortion.
•Clinically important objects may be outside focal trough and therefore may be
distorted or not imaged at all.

7. Clinical uses:
• To assess general devilment if dentition, presence, absence and state if eruption
of teeth.
• Detection of any pathologies
• Evaluation of trauma.
• 3rd molars.
• Extensive disease.
• Suspected large lesion.
• Tooth development.
• Developmental anomalies.
• Retained teeth or root tips in edentulous patients.
• To determine the extent of root resorption of primary teeth and root formation
of permanent teeth

8. o Panorex is made by creating a focal
trough or region of focus within a
generic jaw form and size.
o The focal trough (“Imaginary zone”
exists in one place for each PAN
machine): 3D curved zone or image
layer in which structures are
reasonably well defined on PANs.
o The image seen in a PAN consist
largely of objects within this trough.
o Objects outside this zone are blurred,
magnified, or reduced in size or
distorted to the extent of not being
recognizable .

9. Patient Positioning and Head Alignment:
✓Remove metallic objects (Dental appliances, earrings,
necklaces, hairpins).
✓Pt. should remain still during the procedure.
✓Or Frankfort (Ala Tragus)
✓Tongue touches the Palate

10. Patient Positioning and Head Alignment:
• The anteroposterior position radiograph of the patient is
achieved typically by having patients place the incisal
edges of their maxillary and mandibular incisors into a
notched positioning device (the biteblock).
• The midsagittal plane must be centered.
• Place the patient so that a line from the Tragus of the Ear
to the outer Canthus of the eye is parallel with the floor.

12. A)Chin tilted upward, reverse smile with
the occlusal plane appearing flat or
inverted, condyles directed laterally,
shadow of palate obscure apices of
max teeth, max ant teeth may be
outside of focal trough thus fuzzy.
B) Chin tilted down – exaggerated smile,
mandible wide in a sup-inf direction in
midline, the teeth become severely
overlapped, the chin might be cut off
from film and the condyles might be
cut-off, ant teeth distortion.

13. • Head Rotated toward the left side, magnification of the left side,
overlap of posterior teeth.
• DO NOT mistake fo skeletal Asymmetry

14. Properly acquired pano

15. • Too far forward (closer to film)- image minified, anterior teeth blurred/
minified, overlap of teeth in PM area, spine superimposed on TMJ
• Too far back (away from film)- magnified, wide, blurred anterior Teeth/
magnified, Condyles and post Ramus cut off
• Rotated/Twisted- ant region unaffected, side rotated toward film
narrowed, side away from film widened.
Panoramic Radiograph Positioning Errors

16. Intra-oral Radiographs

18. Aggressive Periodontitis
This is a child, what do u think?
In children and adolescents, central Is and/or 1st molars

19. *You must document that the patient's periodontal status was
amenable to orthodontic treatment prior to initiating care:
1.Patient is 18 years or over.
OR
2. Patient is under the age of 18 and patient has signs/
symptoms of periodontal disease (not gingivitis).
Periodontal pretreatment records should be taken within 6 months prior to
treatment initiation and within 12 months following appliance removal for
posttreatment records.
ABO

20. Utilize one or more of the following methodologies for
periodontal records:
oFull mouth periodontal probing.
oWritten documentation of periodontal status, including a full
periodontal charting, received from a periodontist, general or
pediatric dentist.
oPanoramic radiograph + bitewings + anterior periapical
radiographs.
oFull mouth series of periapical and bitewings.
oCBCT
ABO

21. Lateral Cephalometric Radiograph

22. Cephalometrics
· Evaluation of facial proportions and aesthetics
· Evaluation of Sk and Dental Transverse relations
· Evaluation of Sk and Dental A-P relations
· Evaluation of Sk and Dental Vertical relations
· Growth prediction

23. Cephalometrics
· Review progress towards a treatment goal
· Age / sex / race/ growth prognosis / facial type/malocclusion type
· Spatial relations of facial components
· Growth and different parts of the face
· Treatment progress by ceph superimposition
· Pathology

24. How do we use a Lateral Ceph?
• They are traced to allow the relevant analysis to be undertaken.
• Traced either by hand or on a computer program - called Digitisation
• Computer programs can be used to plan surgical procedures and give
predictions on the surgical outcome

25. What do they show us?
• We can analyse the tracing to determine the variation of our patient from
the average patient.
• To determine the Skeletal and Dental assessment of the malocclusion.
• Help to plan our orthodontic treatment
• Help to decide the prognosis of our planned treatment

26. How do the help us to make our diagnosis?
• Determine the skeletal base discrepancies in antero-posterior and vertical
dimension.
• Determine the effect of soft tissues on the teeth.
• Determine the angulation of the incisors.
• Determine the likelyhood of achieving the intended changes.

27. Lateral Cephalometric Radiograph:
Natural head position!!
• NHP is the orientation of the head that one presents to the world. It is obtained
by having the relaxed patient look at the horizon or, more practically in an
enclosed X-ray room, into his or her own eyes in a mirror.
• Relax the shoulder and neck muscles!!!
• If the ears are not symmetric, putting the ear rod only in the right ear (to
establish the distance between the X-ray source and patient) and then
establishing head position (using the mirror) can prevent distortion.
• The more severe the facial anomaly, the more likely it is that unthinking use of a
cephalostat will produce an image in a distorted head position.

28. Uses of Cephalometrics:
• Diagnosis and treatment planning – allows assessment of:
• AP SK pattern, Vertical SK pattern, dental bases, incisor positions and
angulations, detection of unerupted teeth, soft tissue profile.
• During active treatment to assess efficiency of treatment – e.g. at the end of
functional appliance therapy.
• End of treatment – to assess overall treatment effects.
• During/out of retention – to assess nature of relapse.
• Assessing/monitoring growth – patient’s own growth with serial extraction’s or
comparing with norms for sex, age and race (using Burlington templates).
• Research.

50. • Cephalometric prediction
- Treatment effects
- Growth
- Soft Tissues
- Occlusal
• The borderline patient:
possibilities and limitations
• Extraction patterns in Orthodontic preparation
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT

51. Cephalometric Analysis:
- Comparison to average values
- Comparison to graphical norms
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT

52. - Eight Methods of Analysing a Cephalogram to Establish
Anteroposterior Skeletal Discrepancy
Moira Brown
BJO 1981 8: 139 - 146
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT

53. GROWTH and GROWTH PREDICTION
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT

54. Growth Evaluation
• Growth Spurt
• Duration
• Amount
• Direction
• Age
• Gender
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT

55. BJORK ANALYSIS

56. JARABAK ANALYSIS:
PFH / AFH

57. CBCT

58. CBCT Indications:
• Impacted tooth.
• Orthognathic evaluation/ asymmetry.
• Pathology.
• TMD.
• Craniofacial cases (CLP/syndromes).

59. IMPACTED CANINE

60. ASYMETRY

62. TMJ

63. AIRWAY

64. • If you need PA ceph in addition to the pano and the ceph, just take
cbct from the beginning.
• CBCT is 2-3 times or more compared to pano + ceph but it gives a
lot of information.

65. Hand Wrist

66. Hand Wrist
• Hand wrist to evaluate
growth stage, SMI.
• Now mainly for research
purposes.

67. Thank You