DATE : 24/05/2016

Radiographic Aids In Diagnosis of

Periodontal Diseases Part B

DR. IBRAHIM SHAIKH

MDS III

DEPT. OF PERIODONTOLOGY & IMPLANTOLOGY

SEMINAR NO. - 9

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.

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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Interpretation of an OPG

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.

Osseous Structures

Orthopantomograph
a.Pterygoid
plate
b.Pterygomaxill
ary 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.Infraorbital6
canal
i. Inferior

Osseous Structures

Orthopantomograph

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
7
36.Mental fossa
38.Genial tubercles

Osseous Structures

Orthopantomograph
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
8
25. sigmoid notch
28. cervical

Orthopantomograph
Air/Soft tissue shadows

Orthopantomograph
Ghost images

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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.
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Orthopantomograph
OPG Interpretation
1. 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.
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3. Examine the cortices of the maxilla
. Zygomatic process of the maxilla.

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:
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inferior alveolar nerve canals.
mandibular foramina.

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.
14

Interpretation in relation to
periodontal diseases.

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.

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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

17

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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Morphology of Periodontal Bone

Loss

Angular/Vertical defects

The bone loss is uneven and oblique, centered upon one

tooth more than the adjacent tooth

19

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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Morphology of Periodontal Bone

Loss

Infrabony defects

These refer to focal bone loss

which extends along a root
surface apically. These defects can
be:
Threewalled, where both
buccal and lingual cortices are
preserved.
Twowalled, where a buccal or
lingual cortex is effaced.
Singlewalled, where both
buccal and lingual cortices are
effaced.
A Singlewalled defect appears
lucent and well defined, whereas a
Threewalled defect appears

SingleWalled

21

Morphology of Periodontal Bone

Loss

Infrabony defects

ThreeWalled

Two-Walled

22

One-Walled

Two-Walled

ThreeWalled
23

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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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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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 Jshaped lucent appearance is
sometimes seen.

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Morphology of Periodontal Bone

Loss

27

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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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.

29

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

30

Advances in Radiographs

31

Computer Assisted Densitometric Image

Analysis System (CADIA)
Urs Brgger 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 .

32

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.

33

Computer-Based Thermal Imaging

Probeye Thermal Imaging Systems

34

Computer Software programmes

Denta Scan, i Cat Vision, Carestream 3D Imaging, Sim

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.

35

Digital tomosynthesis (DTS)

K Ogawa et al 2010
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.

36

Digital tomosynthesis (DTS)

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

37

Optical Coherence Tomography

K Ogawa et al 2010
Optical
coherence
tomography (OCT) is an
optical signal acquisition and
processing method
An interferometric technique,
employing near-infrared light.
OCT is
well-suited
periodontal diagnosis.

for

Pocket
morphology,
and
attachment level are digitally
recorded.

38

Optical Coherence Tomography

Otis L.L et. al. 2004
Demonstrate the capacity of
OCT to determine
gingival thickness and the shape and contour of the
alveolar crest.

Xiang et al. 2009

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
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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

40

TACT-tuned aperture CT
Onanong Chai-U-Dom 2002
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
Nair
M K etDSR.
al. 2002
standard
Compared the diagnostic efficacy of tuned-aperture
computed tomography (TACT) and conventional twodimensional direct digital radiography (DDR) in an in
vitro environment for detecting bone loss in midbuccal and lingual crests.
TACT performed significantly better than DDR

41

Small Volume CT
Form of CBCT.
Utilizes small field high resolution detector
generate high resolution 3D volume.

to

Generally comparable to size of intraoral radiographs.

van Daatselaar 2003

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

42

Implant Imaging
43

Implant Imaging

Principles of imaging for dental implant assessment

Images should have appropriate diagnostic quality and
not contain artefacts that compromise anatomicstructure 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.

44

Implant Imaging

Implant Imaging
1. Initial Examination
RECOMMENDATIO
N1

Panoramic radiography
should be used as an
imaging modality.

RECOMMENDATIO
N2

Use IOPAs to supplement

panoramic radiography.

RECOMMENDATIO
N3

Do not use cross sectional

imaging as an initial
diagnostic aid.

Implant Imaging
2. Preoperative site specific 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.

Implant Imaging
2. Preoperative site specific imaging

CBCT imaging should be

considered
if
bone
reconstruction
and
augmentation
procedures
RECOMMENDATIO
(e.g., ridge preservation or
N7
bone grafting) have been
performed to treat bone
volume deficiencies before
implant placement.

Implant Imaging
3. Post-operative imaging
RECOMMENDATION
8

In the absence of clinical signs or

symptoms use IOPAs or OPGs.

RECOMMENDATION
9

Patient has mobility or altered sensation

use cross sectional imaging/CBCT.

RECOMMENDATION
10

Do not use CBCT imaging for periodic

review of clinically asymptomatic
implants.

RECOMMENDATION
11

Implant retrieval - CBCT.

Limitations of Radiographs
50

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 3dimensional 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.
51

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
radiographs.

cannot

be

identified

by

Widening of periodontal ligament does not necessarily

mean tooth mobility.
52

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.

53

Limiting Radiation Exposure

54

Limiting radiation exposure

ADA recommendations 2012
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

Conclusion
56

Conclusion

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.
58

References
1. Clinical Periodontology And 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. 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
59

6. Bragger U: Digital Imaging In Periodontal Radiography-

THANK YOU
Next Presentation On
Thursday 26/05/2016
Journal Club Presentation By
1.Dr. Ibrahim Shaikh
2.Dr. Jyotsna Singh

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