Radiographic aids in dx of periodontol ds part b

- DR. IBRAHIM SHAIKHMDS III

DEPT. OF PERIODONTOLOGY & IMPLANTOLOGY

SEMINAR NO. - 9

Radiographic Aids In Diagnosis of Periodontal Diseases – Part B

DATE : 24/05/2016

2

CONTENTS1. Interpretation of an OPG2. 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.

3

Prichards Criteria (1972)

Adequate angulation1. 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.

4Interpretation of an OPG

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.

6

OrthopantomographOsseous Structuresa.Pterygoid

plateb.Pterygomaxill

ary fissurec.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

OrthopantomographOsseous Structures1. Maxillary sinus 2. Pterygomaxillary

fissure 3. Pterygoid plates4. Hamulus8. Zygomatic process11.Middle cranial

fossa15.Infraorbital canal16.Nasal fossa20.Incisive foramen23.Condyle24.Coronoid process 26.Medial sigmoid

depression30.Mandibular canal31.Mandibular

foramen32.Lingula34.Submandibular

gland fossa36.Mental fossa38.Genial tubercles

8

OrthopantomographOsseous Structures

5. zygomatic arch6. articular eminence7. zygomaticotemporal suture9. external auditory meatus12. lateral border of the orbit13. infraorbital ridge14. infraorbital foramen17. nasal septum18. anterior nasal spine19. inferior concha22. maxillary tuberosity25. sigmoid notch28. cervical vertebrae33. mental foramen39. hyoid bone

9

OrthopantomographAir/Soft tissue shadows

10

OrthopantomographGhost images

11

Orthopantomograph

TMJ Evaluation Bony ankyloses –

Overall obliteration of the joint space. Antegonial notching anterior to the angle of

mandible. Elongation of coronoid process.

Bruxism – Loss of cartilage & erosion of bone over the

condylar head. Flattening & widening of the articular eminence Elongation of coronoid process.

12

Orthopantomograph

OPG Interpretation1. Assess the periphery and corners of the image –

Orbits. Articular processes of the temporal bones (at

the TMJ). 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.

13

Orthopantomograph

OPG Interpretation4. 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.

14

Orthopantomograph

OPG Interpretation8. 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.

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.

17

Periodontal Diseases

Goodson et al. 1984 Should be recognized that radiologically detectable

periodontal bone loss is preceded by clinically detectable inflammatory periodontal disease.

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.

19


Angular/Vertical defects The bone loss is uneven and oblique, centered upon one

tooth more than the adjacent tooth

20


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.

21


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.

Single-Walled

22


Infrabony defects

Two-Walled

Three-Walled

23

Two-Walled

Three-Walled

One-Walled

24


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)

25


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.

26


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.

27


28


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.

29


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.

30


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.

31Advances in Radiographs

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.

33

Computer-Based Thermal Imaging

Probeye Thermal 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.

34

Computer-Based Thermal Imaging

Probeye Thermal Imaging Systems

35

Computer Software programmes

Denta Scan, i Cat Vision, 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.

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.

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.

C Beda in 2010

38

Optical Coherence Tomography

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.

K Ogawa et al 2010

39

Optical Coherence Tomography

Demonstrate the capacity of OCT to determine gingival thickness and the shape and contour of the alveolar crest.

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.

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.

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

Small Volume CT Form of CBCT.

Utilizes small field high resolution detector to generate high resolution 3D volume.

Generally comparable to size of intraoral radiographs.

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

43Implant Imaging

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.

Principles of imaging for dental implant assessment

Implant Imaging

• 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

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

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

3. Post-operative imaging

• In the absence of clinical signs or symptoms use IOPAs or OPGs.RECOMMENDATIO

N 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

50Limitations of Radiographs

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.

52


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.

53


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.

54Limiting Radiation Exposure

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.

ADA recommendations 2012

56Conclusion

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.

59

References1. Clinical Periodontology And Implant Dentistry; Jan

Lindhe; 6th Edn2. Oral Radiology-principles And Interpretation; Stuart C.

White; 5th Edn3. Clinical Periodontology; Newman, Takei, Klokkevold,

Carranza; 10th Edn

4. Radiology In Periodontics – A Review ; J. Indian Academy Of Oral Medicine & Radiology; 2013; 25 (1); 24-29.

5. P.F. Van Der Stelt; Modern Radiographic Methods In The 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

Next Presentation – On Thursday 26/05/2016

Journal Club Presentation By– 1.Dr. Ibrahim Shaikh2.Dr. Jyotsna Singh

THANK YOU

60

Radiographic aids in dx of periodontol ds part b

Healthcare

Transcript of Radiographic aids in dx of periodontol ds part b