RADIOGRAPHIC

INTERPRETATION
DR. ZINNIA PATEL

What is dental radiograph ?

Dental radiography :
It is the art of producing an image or picture
for intra-oral or extra-oral structures on a
dental film using X-rays.

Objectives:

The students should know the normal

anatomy of the tooth under dental
radiograph.

The students should interpret the

pathology of the tooth under dental
radiograph.

It is the traditional method to asses the destruction of

alveolar bone associated with periodontitis.
CONVENTIONAL RADIOGRAPH CAN BE USED TO
EVALUATE

Bone levels
Bone loss even or angular patterns
Intra(infra) bony defects
Root morphologies topographies
Furcation radiolucencies
Endodontic lesions
Endodontic mishaps
Developmental anomalies
Root length and shape(s) remaining in bone

CONVENTIONAL
AND
DIGITAL

RADIOGRAPHS

INTRA ORAL

EXTRA ORAL

IOPA,BITEWINGS
&OCCLUSAL

OPGS

CONVENTIONAL RADIOGRAPHS
INTRA ORAL RADIOGRAPHS

Intra oral periapical

radiographs

Paralleling technique

Also called as right angle or long cone

technique.
X-ray film is placed parallel to long axis of
tooth and central ray of x-ray beam is
directed at right angle to teeth & film.
Preferable technique for periodontal use.

Bisecting angle
technique
Central ray is directed at right angles
to a plane bisecting the angle between
long axis of teeth & film.

Projection Maxilla
Mandible
Projection
Maxilla
Mandible
Incisors
+40 degrees
-15
Incisors
+40 degrees
-15
degrees
degrees
Canine
+45 degrees -20 degrees
Canine
+45
degrees -10
-20degrees
degrees
Premolar
+30
degrees
Premolar
+30
degrees 2-5
-10degrees
degrees
Molar
+20
degrees
Molar
+20 degrees
2-5 degrees

Periapical radiograph:

It is the most frequently

used intra-oral view
radiograph, which shows
the entire tooth and
surrounding structures on
the film.

Need for prescribing peri-apical

dental radiograph

Extent of carious involvement in the tooth

Interproximal decay under the contact

point

Periapical pathological changes

Traumatic injuries to dento-alveolar

process

Periodontal diseases

Dental anomalies

Occult diseases

Prognostic assessment during treatment

planning

Post obturation assessment of endodontic

therapy

Working length measurement during root canal

therapy

Implants

Normal Radiographic
Anatomy
(Peri-apical)

Normal radiographic anatomy

ENAMEL
Most radiopaque structure

DENTINE
Slightly lighter than enamel

PULP CAVITY
Radiolucent lines within the tooth

ALVEOLAR CREST
Gingival margin of the alveolar process
appear as a radiopaque line

PDL SPACE
Narrow radiolucent line around tooth
surface

LAMINA DURA
Radiopaque line representing tooth socket

Radiographic
interpretation:

Interpretation :

Step by step analytical process that

provides an exact idea of the clinical
problem and helps to achieve the
final diagnosis of any particular
lesion.

The importance of
interpretation:

Radiographic interpretation is an
essential part of the diagnostic process.
The ability to evaluate & recognize what
is revealed by a radiograph enable us to
detect diseases, lesions & conditions
which cant be identified clinically.

Steps of interpretation

Localization.
Observation.
General consideration.
Interpretation.
Correlation.

Localization:

Localized or generalized
Position in the jaw
Single or multiple
Size

Observation:

All shadows, other than the localized

shadows of the normal landmarks
must be observed.

For example: shadows in crowns,

cervical area, roots, restorations, size
of root canals, periodontal membrane
space, periapical area, alveolar crest,
foreign bodies, integrity of bone

General consideration:

A radiograph shows only 2

dimensions of a 3 dimensional object
(width and height but not the depth)
Cervical burnout: usually appears as
cervical Radiolucency and
misinterpreted by caries; this occurs
due to less density and more
penetration of rays.
Pulp exposure: never to be
determined from radiograph but only
the proximity to the pulp.

Interpretation:

Studying the features of teeth and bone:

Teeth
Study the whole tooth,(crown, root,
enamel, pulp), number of teeth and finally
supporting structures, (Periodontal
membrane space, lamina dura , alveolar
crest)

Bone:
Changes in bone may include:
1- Changes in density.
2- Changes in the margin
3- Changes inside the lesion.
4- Effect on surrounding tissues.
5- Changes in structure

Correlation:

The final step is to correlate all of the

radiographic features to reach a
radiographic differential diagnosis.
Then to draw a final diagnosis, we have
to correlate other data as case history,
clinical examination, and other diagnostic
aids with the radiographic differential
diagnosis

Metallic restoration

enamel

Dentine
Pulp chamber
Root canal

P/d ligament
alveolar bone

Lamina dura

PERIAPICAL
RADIOGRAPH
INTERPRETATION:

Enamel

Caries of the enamel : appears as

radiolucent area

Enamel hypoplasia: appears as

radiolucent area surrounded with
radiopaque margins

Amelogenesis imperfecta: all the enamel

appear as radiolucent area

Dentin:

Caries of the dentin: appears as

radiolucent area

Dentinogenesis imperfecta: dentin

appear as radiolucent area surrounded by
faint radiopaque margins

Dense in dente: appears as radiopaque

structure within the tooth surrounded by
radiolucent margin

Internal resorption: radiolucent lines on

the apex or lateral side of the root dentin

Pulp:

Calcification of the pulp: appears as a

localized area of radiopacity, if the
calcification is generalized it appears as a
generalized area of radiopacity

Shell tooth: appear as wide pulp chamber

Cementum:

Hypercementosis: appear as radiopaque

area covers the cementum line

Cementoma: appears at the apex of the

tooth as a radiolucent area in its early
stages and converted into radiopaque at
the terminal stages

PDL space:

Normally appear as radiolucent line

surround the root surface

Widening of the space as a result of

osteolytic process e.g, osteolytic osteoma

Narrowing of the space as a result of

osteoblastic process e.g, scleroderma

Pdl space

Widened pdl space

Narrow PDL space

Lamina dura:

Normally appear as radiopaque clear

continuous band covers the alveolar bone
i.e, lining the socket and covers the crest
of the alveolar bone

Discontinuity of the lamina dura indicate

pathological changes

Lamina dura pathology

Normal lamina
dura

Loss of lamina dura

Alveolar bone:
Bone resorption either horizontal or
vertical
Bone loss:
Alveolar bone height
Alveolar bone health
Generalized v/s localized alveolar bone loss

Horizontal bone loss

Vertical bone loss

Metallic restoration :

Restoration done on tooth showing radioopacity.

Status of root filling

(RCT) :

Radio-opacity on the whole pulp chamber

can be seen.

Dental Implant :

Dental implant shows obvious shape and

radio-opacity on radiographs

Extraoral Periapical Radiograph

(Newman And Friedman 2003)
Limitations with intraoral periapical
radiographic imaging:
Advancing age
Anatomical difficulties like large tongue, shallow
palate, restricted mouth opening,
Neurological difficulties, and size of radiographic
sensor
Chen et al in 2007
developed a sensor beam
alignment aiming device for
performing radiographs using
this technique

aiming device with placement of the

sensor

BITEWING RADIOGRAPHS
Records the coronal part of upper & lower dentition
along with periodontium.
USES
1)To study height & contour of interdental alveolar
bone.
(2)To detect interproximal calculus.
(3)To detect periodontal changes
Horizontal bitewing
radiographs
useful for proximal caries
detection
limited use in periodontal
treatment and treatment
planning if bone loss is
advanced

Vertical bitewing radiographs

film is placed with its long axis at 90 to the
placement for horizontal bitewing radiography,
can be helpful in evaluating periodontium
POSITIONING DEVICES FOR BITEWING

Hawe Paro-Bite Centering Device

a positioning aid is advised to reduce the need for repeat
radiographs and hence the unnecessary x-ray exposure
is reduced

Occlusal Radiographs Intraoral

occlusal radiographs enable viewing of
a relatively large segment of dental
arch.

They are useful in patients who are

unable to open mouth wide enough for
periapical radiographs

LIMITATIONS OF RADIOGRAPHS
Conventional radiographs are specific but lack
sensitivity
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

STANDARDIZATION OF RADIOGRAPHS

Constant film position film holders,

stents
Constant tube geometry - Positioning
devices , Cephalostat
Using paralleling techniques
Using vertical bitewings
Using superimposed mm grid

Extraoral radiographs
Extraoral radiographs are taken
when large areas of the skull or jaw must be
examined or
when patients are unable to open their mouths
for film placement.
Useful for evaluating large areas of the skull and
jaws but are not adequate for detection of subtle
changes such as the early stages of dental caries
or periodontal disease.

Conventional panoramic
imaging/Pantamography

OPG radiographs:

An Extra-oral technique which produces a

radiograph with wide view of the maxilla and
mandible.
It's also known pantomography Rotational
panoramic radiography

Indications for OPG

radiographs:

Gross caries

Pain related to a whole quadrant

Orthodontic assessment

Pre-operative assessment

Mandibular fractures

Cysts, tumors , developmental anomalies

Assessment of TMJ

Periodontal disease

Impacted tooth

Implants

LIMITATIONS OF OPG
Image distortion
Lingual structures would be projected higher than
buccal surfaces
Use of screen film combination results in less details
than intral oral images
Production of ghost images
It can be used as a alternative for intra oral full mouth
series when combined with bite wing radiographs

Normal Radiographic
Anatomy
(OPG)

OPG Radiographic
interpretation :

Describing the Lesion

1.
2.
3.
4.
5.
6.
7.

Size
Shape
Location
Density
Borders
Internal Architecture
Effect on adjacent structures

Nolla stages (dentitional status)

:

Panoramic radiographs shows unerupted

tooth and help to diagnose nolla stage
and dentitional status.

Impacted tooth :

Impacted tooth are identified on OPG

radiographs easily as the teeth are
displacement and tilted.

Fractures :

Bone displacement, broken mandible

gives the diagnosis of fracture.

Tumors/lesions:

Ill-defined borders with sclerosis and

ground glass appearance gives the
diagnosis of lesion.

Cyst:

Presence of radiolucency , corticated

borders , locularity and displacement of
tooth shows the diagnosis of a cyst.

Restoration material :

Restoration can be diagnosed by

radiopacity on tooth structures.

Digital radiography
Digital radiography is a superior alternative for film based
imaging
Digital in digital radiography means numeric format of image
content as well as its discreteness
Images are numeric and discrete in two ways
Spatial distribution of picture elements (pixels)
and

In terms of different shades of gray of each of pixels

Digital image

and columns

Collections of individual pixels

organized in a matrix of rows

DIGITAL RADIOGRAPHY

Direct Method
Uses a Charge Couple
Device (CCD) or CMOS
sensor linked with fiberoptic
or other wires to computer
system
CCD receptor is placed
intraorally as traditional
films ,
images appear
on a computer screen which
can be printed or stored

Indirect Method
This method uses a
phosphor luminescence
plate, which is a flexible
film like sensor placed
intraorally & exposed to
conventional x-ray tube.
A laser scanner reads the
exposed plates & reveals
digital image data.

Direct Digital Imaging

Direct digital sensorscomplementary

Components
X-ray source
an electronic sensor,
A digital interface card,
a computer with an analog
todigital converter (ADC),
a screen monitor, software,
and a printer.

charge-coupled device (CCD) or

metal oxide semiconductor active

pixel
sensor (CMOS-APS).
array of X-ray or light sensitive
pixels on a pure silicon chip.

Indirect imaging

Photostimulable phosphor
radiographic
systems

PSP is scanned with a helium-neon laser

beam. The emitted light is captured and
intensifi ed
by a photomultiplier tube and then converted
into
digital data.

ADVANTAGES

image can be instantly viewed by patient &

dentist.

Reduction in radiation received by patient by as

much 50% to 80%
Images can be altered to achieve task specific
image characteristics for eg. density & contrast
can be lowered for evaluation of marginal bone
and increased for evaluation of implant
components.
enables the dental team to conduct remote
consultations.
Computerized images can be stored, manipulated

DISADVANTAGES
Familarity with digital nature of images and understanding of
principles of image manipulation is required
Lack of infection control.

Patient discomfort during placement.

As image can be easily manipulated, it can be misused in legal

proceedings
Grossly overexposed or underexposed images cannot be
corrected

Radiovisiography (RVG)
Duret F et al (1988)
Based on use of CCD
Radio X-ray generator connected to sensor
Visio storage of incoming signals during exposure
and
convertion to gray levels
Graphy digital mass storage unit connected to
various video printout devices
latest version
Trophy has released a wireless
version of their RVG intraoral
sensor named the RVG 6500.

Mechanism of image display

Radiographic
digital detector

Conventional
radiographic
source used to
expose sensor

Detector converts
X-rays to visible
image

Image display on
monitor

Specialized techniques

Introduction of digital radiography

meaningful
in dentistry
utility

applications with

Early detection
Quantitative assessment
3 D imaging

diagnostic

Digital subtraction radiography

Zeidses des Plantes (1935) : 1st demonstrated
use of
subtraction
imaging
Depends up on conversion of serial
radiographs into digital images.
The serially obtained digital images are
superimposed & image intensities of
corresponding pixels are subtracted
If change has occurred
The brighter area represents gain

This technique facilitates both qualitative &

quantitative visualization of even minor density
changes in bone by removing the unchanged
anatomic structures from image

Base line
gain

after one year

bone

COMPUTER ASISTED DENSITROMETRIC

IMAGE ANALYSIS SYSTEM
Introduced by 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
reproducablity

Urs Brgger et al in 1988

CADIA was more sensitive than subtraction
radiography
CADIA was capable of assessing differences in
remodeling activity over 46 weeks after
periodontal surgery
Objective method to quantify alveolar bone density
Deas et al 1991
on monitoring the relationship of CALs and CADIA,
found that prevelance of progressive lesions as
detected by radiograph is higher than previous
accepted data
CADIA is still used in research purposes for
detecting quantitatively the alveolar bone
density

Radiographic Changes
in
Periodontitis

1. Fuzziness and a break in the continuity of the lamina dura at the mesial or
distal aspect of the crest of the interdental septum have been considered as
the earliest radiographic changes in periodontitis.

The presence of an intact crestal lamina dura may be an indicator of

periodontal health, whereas its absence lacks diagnostic relevance.

2. A wedge-shaped radiolucent area is formed at the mesial or distal aspect

of the crest of the septal bone .
The apex of the area is pointed in the direction of the root. This is produced
by resorption of the bone of the lateral aspect of the interdental septum,
with an associated widening of the periodontal space.

3. Fingerlike radiolucent projections extend from the crest into the

Septum.
The radiolucent projections into the interdental septum are the result of the
deeper extension of the inflammation into the bone.

4. The height of the interdental septum is progressively reduced by the

extension of inflammation and the resorption of bone.

Radiographic Appearance of Interdental Craters

Interdental craters are seen as irregular areas of reduced
radiopacity on the alveolar bone crests.
They are generally not sharply demarcated from the rest of the
bone,
with which they blend gradually.
Radiographs do not accurately depict the morphology or depth of
interdental craters, which sometimes appear as vertical defects.
The real morphology and topography of interdental craters can
only be seen by surgical exposure.

Radiographic Appearance of Furcation Involvements

Definitive diagnosis of furcation involvement is made by clinical
examination, which includes careful probing with a specially
designed probe (Nabers probe).
Radiographs are helpful but show artifacts that make it possible for
furcation involvement to be present without detectable radiographic
changes.
As a general rule, bone loss is always greater than it appears
in the radiograph.

To assist in the radiographic detection of furcation involvement

the following diagnostic criteria are suggested:
1. The slightest radiographic change in the furcation area should
be investigated clinically, especially if there is bone loss on
adjacent roots.
2. Diminished radiodensity in the furcation area in which outlines
of bony trabeculae are visible suggests furcation involvement.
3. Whenever there is marked bone loss in relation to a single
molar root, it may be assumed that the furcation is also involved.

Radiographic
Appearance of
the Periodontal
Abscess

The typical radiographic appearance of the periodontal abscess is

that of a discrete area of radiolucency along the lateral aspect of
the root.
However, the radiographic picture is often not typical because
of many variables such as the following:
1. The stage of the lesion. In the early stages the acute
periodontal
abscess is extremely painful but presents no radiographic
changes.
2. The extent of bone destruction and the morphologic changes
of the bone.
3. The location of the abscess. Lesions in the soft tissue wall of a
periodontal pocket can not be seen in radiographs. Similar to
abscesses on the facial or lingual surface.
Therefore the radiograph alone cannot be relied on for
the diagnosis of a periodontal abscess.

Radiographs and clinical probing

Regenerative and resective flap designs and incisions require prior
knowledge of the underlying osseous topography.
Careful probing of these pocket areas after scaling and root
planing often require local anesthesia and definitive radiographic
evaluation of the osseous lesions.
Radiographs taken with periodontal probes or other indicators
(e.g., Hirschfeld pointers) placed into the anesthetized pocket
show the true extent of the bone lesion.

Radiographic Changes in
Localized Aggressive
Periodontitis

Localized aggressive periodontitis is characterized by a combination of the

following radiographic features:
1. Bone loss may occur initially in the maxillary and mandibular incisor and/or
first molar areas, usually bilaterally, and results in vertical, arclike destructive
Patterns.
2. Loss of alveolar bone may become generalized as the disease progresses
but remains less pronounced in the premolar areas.

Radiographic
Changes in
Trauma from
Occlusion

Trauma from occlusion can produce:

Radiographically detectable changes in the lamina dura, morphology of the
alveolar crest, width of the periodontal space, and density
of the surrounding cancellous bone.
Traumatic lesions manifest themselves more clearly in faciolingual aspects,
because mesiodistally, the tooth has the added stability provided by the
contact areas with adjacent teeth.
Therefore slight variations in the proximal surfaces may indicate greater
changes in the facial and lingual aspects.

The injury phase of trauma from occlusion:

produces a loss of the lamina dura that may be noted in apices, furcations,
and/or marginal areas. This loss of lamina dura results in widening of the
periodontal ligament space.
This change, particularly when incipient or may be confused with technical
variations due to x-ray angulation or malposition of the tooth it can be diagnosed
with certainty only in radiographs of the highest quality.
The repair phase of trauma from occlusion
Radiographically, this is manifested by a widening of the periodontal ligament
space, which may be generalized or localized.
Variations in width between the marginal area and midroot or between the midroot
and apex are detected, it means that the tooth is being subjected to increased
forces.

More advanced traumatic lesions :

May result in deep angular bone loss, which, when combined with
marginal inflammation, may lead to intrabony pocket formation.
In terminal stages these lesions extend around the root apex, producing a
wide radiolucent periapical image (cavernous lesions).

Root resorption may also occur as a result of excessive forces on the

periodontium, particularly those caused by orthodontic appliances.
Although trauma from occlusion produces many root resorption areas,
they are usually of small and difficult to be detected radiographically.

Additional
Radiographic Criteria in
the
Diagnosis of
Periodontal Disease

Radiopaque horizontal line across the roots. This line demarcates

the portion of the root where the labial and/or lingual bony plate has been
partially or completely destroyed from the remaining bone-supported
portion

Vessel canals in the alveolar bone.

linear and circular radiolucent areas produced by interdental
canals and their foramina.
These canals indicate the course of the vascular supply of the bone and
are normal radiographic findings.
This is often so prominent, particularly in the anterior region of the
mandible, that they might be confused with radiolucency resulting from
periodontal disease.

Differentiation between treated and untreated periodontal disease.

It is sometimes necessary to determine whether the reduced bone level
is the result of periodontal disease. or if destructive periodontal
disease is present.
Clinical examination is the basic determinant. However, radiographically
detectable alterations in the normal peripheral outline of the septa are
corroborating evidence of destructive periodontal disease.

bibliography

Text book of radiology-white and pharow

Text book of periodontology-carranza

112