Advances In Radiographical Assessment

Dental radiographs are one of the traditional methods used to assess the
destruction of the alveolar bone associated with periodontitis. Radiographs do not
accurately reflect the bone morphology buccally and lingually and it provides useful
information on interproximal bone levels. Moreover, it is the only non-invasive
method to determine root length, root proximity, presence of periapical lesions and
estimation of the remaining alveolar bone.5

However, it is well known that substantial amount of alveolar bone must be

destroyed before the loss is detectable on the radiographs (at least 30%).

The conventional radiographs are highly specific but lack sensitivity. The low
degree of sensitivity is mainly due to the subjectivity of radiographic assessment and
to inherent source of variability affecting the conventional radiographic techniques
namely.

a) Variation in projection geometry.

b) Variation in contrast and density due to differences in film processing, voltage
and exposure time and.
c) Masking of osseous changes by other anatomic structures.
The radiographic image is the result of X-rays (roentgen rays passing through
the area of interest and exposing the silver halide emulsion on the
radiographic film. The relative absorption and transmission of the beam.

X-ray beam is determined by the composition of the area of interest.

Radiographs are used to assess bone support in one of three major ways. These
include:
a) Interpretation of the radiographic image
b) Measurement and
c) Image processing

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Interpretation of the radiographic image by transillumination on a view box is the

method most frequently used in clinical practice. Measurements taken from the
radiograph allow quantification of the extent of bone loss along the root surface
using very simple methods such as a grid or schei ruler or state of the art
computerized techniques.
Regardless of the method used reliable and accurate assessment of bone support is
only as good as the radiograph itself. These methods are discussed in more detail
below.

TECHNIQUE IN RADIOGRAPHIC VIEW

Various radiograph projections have been designed to increase likelihood of

obtaining different type of information. The periapical view has been designed to
minimize distortion of the bone to root relationship while imaging the root apex. To
achieve the accurate representation of the bone height along the root surface, the
central ray must be perpendicular to the area of interest and the intraoral film.
Periapical films are susceptible to operator errors especially in the maxillary molar
region. The resulting film may therefore, exhibit a distorted bone tooth relationship
which manifest as foreshortening or elongation and the bone may even appear to
cover enamel of the teeth, making misdiagnosis possible. The quality of the
periapical film may be evaluated by examining the cusp tips of the posterior teeth,
buccal and lingual cusp tips should appear approximately at the same level. When
cusp tips appear are different levels the film probably has misangulation which also
distorts the apparent location of the bone height along the root surface. It is this
misangulation, that results in the radiographic technique of “growing or losing bone”
independent of any true change due to therapy or disease progression.
Techniques are readily available to minimize this source of distortion in the
dental office.

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METHODS TO CONTROL RADIOGRAPHIC ERRORS

Radiographs are the traditional method for assessing the destruction of alveolar
bone associated with periodontitis. The variables of angulation, direction of roentgen
rays, exposure parameters and radiographic processing all contribute as sources of
major errors and therefore, decrease the sensitivity of radiographs as quantitative
tools to measure the bone loss.33
The errors caused by misangulation and x-rays direction combine as sources
of geometric distortion of the radio graphic image. A misangulation error occurs
when the film angulation is changed while the radiographic sources are held
constant. The distortion that is produced may be retrospectively corrected with the
aid of a computer matrix transformation algorithm.
The x-ray direction error occurs when the radiographic source is moved and
the object and film are held in a constant position.

The errors of angulation and x-ray direction as sources of geometric distortion

may be reduced by the use of standardized radiographs in a clinical trial or by the
utilization of a matrix transformation algorithm. Standardized radiographs are
generally achieved using 1 to 3 methods. Most standardization techniques utilize
rigid intraoral source mounting devices (stents). Many investigators have used
processed acrylic occlusal stents which physically fix the geometry between the film,
occlusal surface of the teeth and the radiographic cone. Alternatively, an extraoral
geometric standardization method using a cephalostat head holder and a long film-
to-object distance has been described.

Advantages:
The methods were found to have excellent standardization. The use of
standardized radiographs is better than cephalometric radiograph as it is of low cost.
A real time video feedback method has been recently developed for
standardization of image geometry for intraoral radiography. The video method to
stabilize film utilizes a stored image of the face taken at the time of the first

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radiograph. Prior to exposure of a second radiograph, the subject is aligned when the
monitor has a neutral gray appearance. Validation studies indicate that this method
can be used in anterior teeth with a mean angular discrepancy of 0.31 degrees.
When these radiographs are used to produce subtraction images, lesions may be
detected with 93% sensitivity.

Limitations:
The use of transformation matrix algorithms allows the correction of planar
geometric projection errors. These methods identify distinct landmarks on a correctly
angulated film and then warp the second image into the first. These methods do
have various limitations. If the film is bent or the source to object geometry is
changed between radiographic examinations, a 3-Dimensional distortion will occur
which is not restorable with the software. Another potential limitation is the
identification of landmarks on an inconsistently shaped structure, such as trifurcated
molars. The advantages of transformation techniques are that they use conventional
radiographic methods and are suitable for evaluation of large prospective studies and
retrospective studies of previously available data bases.

In much the same way that angulation of the film and direction of the
roentgen rays contribute to major projection geometry errors, the combination of
exposure parameters and radiographic processing contribute to major errors in
radiographic contrast. The exposure parameters on most radiographic machines are
adjustable and should be checked and written down for each subject. Minor errors
may still occur due to voltage fluctuations, but these may be retrospectively
corrected with contrast correction algorithms.

Radiographic processing may significantly impact on the data analysis from

radiographs in long clinical trials. Contrast changes due to developing time,
temperature of the chemicals, age of the chemicals and differences between
processors may lead to errors. One solution for short clinical trials is to save all films
until the trial is completed and develop the film with new chemicals by hand at the

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same time to ensure uniform processing. This method is clearly not practical for long
trials or multi-center studies in which the number of films may be great. Second, this
does not allow for retaking any of the radiographic exposures and leaves the
opportunity for lost data. In an attempt to standardize densities, step wedges have
been placed on dental radiographs in non diagnostic regions during exposure. After
processing, the examiner does a micro-densitometer reading of the steps of the
wedge and if they match, the films are considered to have the same contrast. The
limitation of this method is that if the steps do not give the same reading there is no
way, short of retaking the film, to try to correct for the contrast error.

A digital method permitting retrospective correction of film contrast

differences has been developed. The method is nonparametric and derives the
required gray level transformation directly from the histogram associated with the
radiographs. It should be noted that the use of a contrast correction algorithm does
not relieve the examiner from attempting to control exposure and processing
artifacts.

The various radiographic methods along with their limitations and potential
applications are listed.

First : A long cone should always be used. The relatively parallel rays minimize the
distortion of the image that would be caused by a divergence of the beam between
the bone and teeth and the film.

Second : The use of paralleling positioning devices helps the technician standardize
the relationship between film, object and X-ray source.

Several such devices have been described and are commercially available
recently. One device has incorporated a positioning rod to further facilitate the
exposure of high-quality radiographs.

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Improving clinical intraoral radiographs for periodontal assessment

Action Reason
Use vertical bitewing where Decreases patient exposure compared with full
possible mouth series
X-ray beam is perpendicular to the alveolar crest
Decreased time to perform the examination
Use 90kVp Increased gray-level information in film imporves
ability to see changes in bone height Decreased
radiation dose to tissues
Use superimposed millimeter Facilitates detection of bone loss over time
grid
Use root length ruler Facilitates detection of bone loss over time.

Bite wing view

Bitewing radiographs are taken with the x-ray beam perpendicular to the
bone and the tooth root, thus, minimizing the distortion of the location of the bone
height along the tooth root. In conventional bitewing film a limited view of the
osseous crest is available, so even moderate bone loss due to periodontitis may
preclude its usefulness as a diagnostic image. More recently vertical bite wing films
have been taken with the long axis of the film placed vertically in the mouth in either
anterior or posterior sites. The resulting film shows considerably more bone and can
be used to assess bone height in patients with moderate to severe bone loss. The
radiation dose is reduced compared with individual periapical films because several
maxillary and mandibular teeth are viewed in one image. The bone height is
generally imaged very accurately along the root surface due to the ease of directing
the X-ray beam perpendicular to the tooth either by eye or using specially designed
vertical bite wing positioning devices.

Selection for the film type and X-ray setting:

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The quality of the intraoral radiograph for periodontal diagnosis and the
radiation dose to the patient are influenced by the selection of knowledge and film
speed. Dental films for intraoral use are presently available in two speeds, Ultraspeed
(D) and Ektaspeed (E). These two film speeds have replaced the slower films available
in the past. Essentially the difference between the two films is the grain size in the
emulsion. The larger the grain size, the less details in the image but the faster the
exposure. Therefore, D speed film provides somewhat more details on a microscopic
level, but does so by using twice the radiation dose of E speed films.

X-ray machine settings are also of importance because they influence the
image quality and radiation dose they influence the image quality and radiation dose
Dental radiographs are generally taken at either low kilovoltage (65*70k Vp) or high
kilovoltage (90kVp). The kilovoltage of the X-ray beam is related to the energy of the
beam. This means that lower kilovoltage X-rays are more likely to be absorbed by the
tissues resulting in a radiographic image with a dark background and high contrast.
These higher contrast films are especially useful for diagnostic tasks that require a
high contrast image such as locating a file at the apex in root canal treatment
procedures. Higher kilovoltage X-rays are less likely to be absorbed by the tissues and
result in lower contrast radiograph that show more shades of gray. The result is less
radiation dose to the patient and an image that shows more shades of gray. Thus,
these radiographs contain more information about the density and height of crestal
bone and are the therefore well suited for the assessment of tooth or implant
supporting structure.

PANAROMIC IMAGING

Panoramic imaging (also called pantomography) is a technique of producing a single

tomographic image layer of facial structure that includes both maxillary and
mandibular dental arches and their supporting structures. This is a curvilinear variant
of conventional tomography and is based on the principle of the reciprocal moment
of an x-ray source and an image receptor around a central point or plane, called the
image layer, in which the object of interest is located. Object in front of or behind this

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layer is not clearly captured because of their moment relative to the center of
rotation of the receptor and the x-ray source.

The principle advantage of the panaromic images includes the following:

Broad coverage of facial bone and teeth, low patient radiation dosage, it can be
used in patients who are unable to open their mouth, short time is required in making
the panaromic images, usually in the range of 3 to 4 min (inducing the time necessary
for positioning the patient and the actual exposure cycle. Patient ready
understandability of panaromic films makes them a useful visual aid in patient’s
education and case presentation.
Panaromic images are more useful clinically for diagnostic problems require a
broad coverage of jaws. common example includes evaluation of trauma, location of
third molar, extensive disease, known or suspected large lesion, tooth
development( especially in mixed dentition), retained teeth or root tips( in
edentulous patients), and developmental anomalies.
The main disadvantage of panaromic radiography is that the image does not
display the fine anatomical details available in the intraoral periapical radiographs.
Thus, panaromic image is not useful as periapical radiograph for detecting the small
carious lesion, fine structure of marginal periodontium or periapical disease. The
proximal surface of the premolars also overlap. Other problems associated are
unequal magnification and geometric distortion across the image.

PRINCIPLES OF PANAROMIC IMAGE FORMATION

The first to describe the principle of panaromic radiography were Paatero and,
working independently, Numata.

Operation of a panaromic machine: Two adjacent discs rotate at a same speed in

opposite direction as the x-ray beam passes through their center of rotation. Lead
collimator is in the shape of a slit, located at the x-ray source and at an image
receptor, limits the central ray to a narrow vertical beam. Radiopaque objects A, B, C

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and D stand upright on disk 1 and rotate past the slit. The image is recorded on the
receptor, which also moves past the slit at the same time. The objects are displayed
sharply on the receptor because they are moving past slit at the same rate and in the
same direction as the receptor. This causes their moving shadow to appear stationary
in relation to moving receptor. Other object between the letter and the center of
rotation of the disk 1 rotates with the slow velocity and are blurred on the receptors.
Any object between the x-ray source and the center of the rotation of the disk 1
move in opposite direction of the receptor, and their shadows are also blurred on the
receptor.
Most panaromic machines now use a continuously moving center of rotation rather
than multiple fixed locations. This feature optimizes the shape of image layer to
reveal the teeth and supporting bone. This center of rotation is near the lingual
surface on the right body of mandible when left temporomandibular joint is imaged.
The rotation center moves forward along an arc that ends just lingual to the
symphysis of mandible when midline is imaged. The arc is reversed and opposite side
of face is imaged.

Digital radiography,digital image acquisition and display

The computer is in charge of all components of the digital imaging system. It
instructs the X-ray generator when to start and stop the exposure, controls the
digitizer (analog to digital converter), constructs the image by mathematical
algorithm, determines the method of image displaced and provides for storage and
transmission of acquired data. Images may be acquired by radiographic film or by
detectors which are solid state electronics devices.
The most common detectors are the charged couple device (CCD). 34 The CCD
consists of chips of pure silicone with inactive area that has been divided into two
dimensional arrays of elements called pixels. When electro magnetic energy in the
range of either visible light or X-ray interacts with pixels of a CCD an electric charge is
created and the pixels are able to store in the same fashion as the capacitor does.
The total charge developed and stored by a pixel is proportional to the energy
incident on the pixel. Following exposure of the CCD to the radiation, charges stored
by the individual pixels are sequentially removed electronically, creating an analog

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output signal whose voltage is proportional to the charges on each of the pixels in
succession.
Analog information, such as the output signal from the CCD is any data
represented in the continuous fashion. The analog to digital converter or digitizer is
used to change the analog output signal from the CCD detectors to a numeric
representation, based on the binary number system, which is recognizable by the
computer.
The task is accomplished by measuring the voltage of output signal at discrete
intervals and then by assigning the number (0 to 255) to the intensity of the voltage.
Thus, 250 voltage levels can be discriminated that ultimately will be displayed in
image form following computer manipulation as 256 shades of gray. In contrast
human eye is sensitive to only 32 shades of gray. Digital imaging methods can be
indirect or direct.

INDIRECT DIGITAL RADIOGRAPHY

Indirect digital radiography uses radiographic film as the image receptor. The image
digitized from the output signal of a video camera or scanner that views the
processed radiograph.
This digital processing of images recorded by radiographic film may serve
several useful purposes:
a) The ability to manipulate digital images allows for the optimization of the
image quality in terms of contrast and density, which embodies the potential
for enhanced perception of details and improved diagnosis.
b) As direct digital radiographic dose, digitization of radiographic images provide
for the storage of information.
c) This information can be transmitted to remote sites for consultation as digital
images processing of direct exposure non-screen films may result in loss of
information because the digitized image represent second generation.

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Indirect digitized radiography can be accomplished by several means. One system

(Fuji Photo, Tokyo, Japan) uses a photomultiplies tube with a small aperture
(100×100 cm) to see an illuminated radiograph. The analog output signal from the
photomultiption is digitized by an analog to digital converter and the digital data is
processed by computer and fed into a digital analog converter, whose output is used
to moderate the light intensity of a glow tube.

The right output from the glow tube is directed to a sheet of radiographic film and
image is recovered following the standard processing procedures.
Other systems employ a television camera as a sensor and a television
monitor and/or video printer as the display.
Regardless of the method of acquisition and display, the result is same i.e.
digital image pertaining to information is obtained that can be manipulated and
stored.

DIRECT DIGITAL RADIOGRAPHY

The methods of measuring radiographic change in bone support with
periodontal disease previously described have utilized all indirect digital imaging
techniques. The process of converting an intraoral transmission radiograph to a
digital image is down with a video camera coupled to a frame grabber capable of
storing an entire video-frame in solid state memory. The development of low cost
frame grabbers that may be installed in personal computers has made the use of
digital methods practical for longitudinal clinical trials in dentistry. Further, the
availability of optical disk drives for personal computers make mass storage of
radiographic image readily possible.5

An alternative to this workstation is recently available by the development of

miniaturized direct digital detectors with the ability to be used intraorally. The
radiographic digital detector is placed intraorally at the region of interest with a
positioning device. A conventional clinical radiographic source is used to expose the
detector. The detector converts the X-rays to a visible image that is immediately

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displaced on a video monitor. The technology involved is very similar to the method
by which the charge-coupled device in a home video camera is able to create a video
image of a subject. The advantage of this system is that, the images obtained are
immediate and thus the time required for processing and indirect digitization is
eliminated. Further, the gray level of the image may be adjusted before it is stored by
the computer. Additionally, since the direct digital detector is much more sensitive
than dental radiographic film, the exposure dose may be reduced by approximately
91% to 96%. This dose reduction may become a very important factor in advancing
clinical trials by allowing more frequent data collection time.

The use of direct digital detectors is limited by the size of the detector itself.
The thickness of the detector may make positioning it somewhat uncomfortable for
the patient. The usable image size is about 60% of that of the conventional dental
film which may require additional exposures to gain the same information. The
resolution of the detector is another current limitation. The resolution of the
detectors currently available is limited and one must weigh the advantages of dosage
reduction against the loss of resolution. A final limiting factor is the lack of technical
support that is available for this relatively new technology and the expense of the
equipment.

Advantages of direct digital radiography

1. Immediate image display with no waiting for dark room processing.

2. Ability to manipulate the image by contrast enhancement or gray scale
reversal.
3. The patient dose reduction of 60% compared to E-speed film and 77%
compared to D-speed film.
4. The contrast and brightness of the image may be adjusted after the image is
exposed. So that artifacts such as burn out of thin bone do not adversely
impact the diagnostic utility of the image.

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5. Digital images can be stored and retrieved to facilitate the measurement of

bone loss along the root surface. It is a very useful tool guiding the placement
of implants and having a follow up.

DISADVANTAGES:
The number of images required is more for a full mouth examination as each
digital image may include one molar or two anterior or premolar teeth. This
diminishes the effect of exposure reduction.
It has decreased image resolution and contrast compared to a radiographic
film. The maximum resolution of RVG (3rd generation) is reported to be 11 lines per
mm which is still considerably lower than 20 lines per mm capability of radiographic
film. The regam medical system (sundsvall, swedan) has introduced a digital
system called the sens-a-rat and visualix (monza, italy). They differ from RVG in
detector construction. Each utilizes a CCD that is sensitive to direct action of x-rays,
where as in the RVG system the CCD responds to the light generated by the
intensifying screen.
Current evidence suggests that digital systems perform comparably with film
radiography for the detection of periodontal bone lesion and occlusal caries in non
cavitated tooth. The rapid image acquisition and reduced radiation exposure per
image may prove to be advantageous for imaging during the course of endodontic
therapy.

RADIO VISIO GRAPHY

A new radiographic system called Radio Visio Graphy (RVG) digitizes ionizing
radiation. Developed in France by Dr. Francis Mouyen35, the system provides an
instantaneous image on a video monitor while reducing radiation exposure by 80%
The RVG device has three components. The “Radio” component
consists of a hypersensitive intraoral sensor and a conventional X-ray unit. The small
sensor (24 by 37 by 11mm) contains a flucoroscopic sensor screen, a set of optic
fibers, and a miniature charged coupling device that translates the image produced
into an electronic signal that is subsequently transmitted to the display-processing

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unit. For infection control, disposable latex healths are used to cover the sensor
when it is in use, the sensor itself is cold sterilized while the sensor positioners are
autoclavable. An exposure time in the range of hundreadths of a second is all that is
needed to generate the image.
The second component, the “Visio” portion, consists of a video monitor and
display-processing unit. As the image is transmitted to the processing unit, it is
digitized and memorized by the computer. The unit magnifies the image four time for
immediate display on the video monitor and has the additional capability of
producing colored images. It can also display multiple images simultaneously,
including a full-mouth series on one screen. Because the image is digitized, further
manipulation of the image is possible; this includes enhancement, contrast
stretching, and reversing. A zoom feature is also available to enlarge a portion of the
image upto full screen size.
The third component is “Graphy” a high-resolution video printer that instantly
provides copy of the screen image, using the same video signal.
The advantages of RVG seem to be numerous, but the primary ones include
the elimination of x-ray film display. A recent study showed that RVG resolution was
slightly lower than that produced with silver halide film emulsion, but radiographic
information can be increased with the electronic image treatment capabilities of the
system.

3 - DIMENSIONAL IMAGING METHODS

The methods presented to this point have addressed the identification of a 1-
dimensional change in the periodontal support structures by addressing bone height
measurements of 2-dimensioal area change measurements. The advent of digital
subtraction imaging and tomography has allowed the first quantitative assessment of
attachment loss in 3 dimensions. The best known computer aided technique is digital
subtraction radiology (Webber et al., 1982; Grondahl & Grondahl, 1983; Jeffcoat et al
1987).

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Subtraction radiography:
In digital subtraction radiography, a standardized radiographic image is
obtained before the appearance of an anatomical change, such as crested alveolar
bone loss and the subtracted image is that of the isolated structures which has
undergone the change. By definition, the structures that have not changed will
appear dark gray and areas of the bone gain will appear light gray.
Once the subtraction image is stored it may be electronically contrast
enhanced to display the final image to its best advantage. This involves
mathematically manipulating the pixels aimed at increasing the readability of the
image. An image may be enhanced by addition or subtraction of a constant value to
each pixel which would produce the same result as increasing or decreasing
(respectively) the exposure time of the original radiograph. Alternatively, image
stretching may be used to spread the digital data over a wider range of gray values,
which would be analogous to altering contrast. Color may be added by selectively
assigning different color to the shades of gray. Although color does not add
information to the image and may not be helpful to the experience examiner, by
adding color, features of an image that may differ by very subtle shading can be
made much more visible by presenting features in vividly contrasting colors. In one
study of color contrast-enhanced subtraction image untrained examiner was 23 times
more likely to make a correct diagnosis of a color enhanced lesion.
Several methods have been proposed to quantify the size of the bony change.
One such method provides a 2-dimensional quantification by determining the area of
the color-enhanced pixels. The area of the lesion may be determined by using a
morphologically-aided technique which also removes background noise from the
image. The subtraction image is converted to a binary image in which all the pixels
are either white or black.
The operator adjusts the threshold until the isolated lesion is black against a
scattered black and white background. The borders of the osseous defect are more
completely defined by using a combination of erode and dilate filtering operations.
An erode operation is performed to remove the isolated pixel noise. A dilate
operation is then performed to restore the area of the lesion to its approximate

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original area. The resultant image may then be combined with the original
radiograph so that the area of change may be visualized along with the clinically
relevant structures.
To obtain a 3-dimensional estimation of the alveolar bone loss, the thickness
of the lesion must also be determined. A calibrated reference is often positioned at
the interocclusal surface in order to prevent the reference from obscuring a
diagnostic region of interest. Most commonly, a continuous wedge of aluminum or
hydroxyapatite is used as the radiographic reference. The reference wedge is only
required to be placed on the original film of the series. The subtraction images
obtained from the subtraction of subsequent films will demonstrate any change in
the anatomy and also any negative image of the wedge. A computer algorithm then
determines the area of the lesion. The algorithm uses the dimensions of the
reference wedge to convert the area in pixels to square millimeters. It then reads the
gray level change on the subtracted wedge image until the gray level of the lesion is
exceeded. At that point, the mean thickness of the lesion is calculated. The area and
thickness estimates are used to calculate volume and the density of bone is used to
express the data in mass equivalents of cortical bone. Other methods have been
described including use of the gray levels to provide an index of bony change in
CADIA units and the use of a dual film cassette to correct the non-linearities.

Technically, subtraction imaging approaches are exciting and labor-intensive

and any increase in precision should be weighed against the man-power and cost
involved in the use of these approaches in a clinical trail. The quantification of lesion
size is only necessary when data is needed to be compared between subjects. A
relative quantification of lesion expansion or healing is adequate within- patient
comparison is made longitudinally. Moreover, the clinical significance of the change
measured needs clarification. For example, what is the clinical importance of an
increase in the thickness of a lesion without a linear loss of bone height along the
root surface. The use of 3-dimensional techniques increase precision but also adds a
numbers of minor errors in the attempt to quantity. The approaches described do
not account for errors such tissue attentuation, beam hardening, scatter, and other

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nonlinear processes. These processes may limit the precision of quantification in a

clinical trial but are most likely insignificant in comparison to the major error of
projection geometry and radiographic contrast in longitudinal studies.35

COMPUTER ASSISTED DENSITOMETRIC IMAGE ANALYSIS (CADIA)

This video-based technique was introduced for periodontal diagnosis by

Bragger et al (1998) In this technique, the radiographs are viewed by a video camera
linked to an image processor, digitized and the image displayed on the screen of the
analyzer. It is possible to store the images and manipulate them e.g. enhancing the
contrast. Tooth root and alveolar bone height can be measured to an accuracy of
0.01 mm. It is the most sensitive method of visualizing the alveolar crest,
cementoenamel junction and measuring the radiographic bone loss in periodontal
surgical site.
TOMOGRAPHY

Convectional film based tomography also called body sectional radiography, a

radiographic technique designed to image clearer object lying within the plane of
interest. This is blurring structure lying outside the plane of interest through the
process of motion unsharpness.

Essential equipment includes x-ray tube and radiography film rigidly

connected to scapable of moving about a fixed axis or fulcrum. The examination
begins within the x-ray tube and film positioned on the opposite side of interest
which is located within the body plane of interest (focal plane). An exposure begins,
tube and film move in opposite directions simultaneously through a mechanical
linkage.34
With synchronous movement of tube and film the image of the object located
within focal plane (at the fulcrum) remains at the fixed position on the radiographic

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feature throughout the length of the tube and the film travels and are clearly
imaged.
The objective of tomography, then, is to blur the images of structures not
located in focal plane both as much and as uniformity as possible. Blurring is greater
under the following condition:
 Farther the structure lies from the focal plane and greater the distance
between the structure and the film (determine by physical location of
fulcrum within the object to be imaged and hence the diagnostic task
to be accompanished).
 The more closely the long axis of the structure to be blurred is
oriented perpendicular to the direction of tube travel (accompanished
by tomographic movement).
 Greater the amplitude of tube travel ( determine by tomographic
angle or arch)

There are five types of tomographic movements: linear, circular, elliptical,

hypocycloidal and spiral. Mechanically the simplest tomographic moment is linear.

Linear tomography can be accompanished in two ways:

1) X-ray tube and film moves in opposite directions about the fixed fulcrum
in the path of travel parallel to one another
2) Both the x-ray tube and the film move along concentric arc rather than in
a straight line.
Currently used x-ray unit used both the methods, which give similar results.
There are two types of tomography
a) Wide angle tomography.
b) Narrow angle tomography.

WIDE ANGLE TOMOGRAPHY: it is a type of tomography which uses tomographical

angle greater than 10 degree, thus, allowing visualization of the of the fine structure

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that normally would be obscure by superposition in the conventional radiography.

Using this technique, layer as thin as 1mm can be imaged.
The wide angle tomography is an excellent technique for evaluating maxilla and
mandible before placing dental implants.

NARROW ANGLE TOMOGRAPHY: angle of less than 10 degree is used, also called
zonography because a relatively thick zone of tissue (up to 25mm) is sharply imaged,
it is particularly useful when subject contrast is low because of little difference in
physical density between the adjacent structures.

STEROSCOPY

It is not a new technique by J.Mackenzie Davidson introduced in 1898.33

Over the next few years, this technique grew in popularity among radiologist because
of its educational value and understanding the normal anatomy is simplified with
stereoscopic images.

Stereoscopy imaging requires the exposure of two films, one for each eye, and
thus, delivers twice the amount of radiation to the patient. Between exposures the
patient is maintained in the position, film is changed and tube is shifted from the
right eye to the left eye position. After processing, the film commonly is viewed with
a stereoscope that uses either mirror or prism to coordinate the accommodation and
convergence of the viewer’s eye so that brain can fuse the two images.

Stereoscopy currently enjoys a renewed interest for the evaluation of bony

pockets in patients with periodontal diseases, morphology of temporomandibular
joint area, determination of root confrigation of the teeth that require endodontic
therapy, assessment of the relationship of the mandibular canal to the root of
unerupted mandibular third molars and assessment of bone shape when placement
of dental implants is considered.

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COMPUTED TOMOGRAPHY

Godfrey Hounsfield (1972)33 invented a revolutionary imaging technique i.e.

computed tomography (CT) and claimed it to be 100 times more sensitive than the
conventional x-ray. The CT image is reconstructed by computer which mathematically
manipulates the transmission data obtained from multiple projections.
ADVANTAGES OF CT
1) It completely eliminates the superimposition of image of structures
superficial of deep to the area of interest within the patient.
2.) Because of the inherent high contrast resolution of CT differences may be
distinguished between tissues that differ in physical density by less than 1%.
3.) Multiplaner image in the axial, coronal and sagittal planes can be viewed.

Computed tomography is known by many names namely, computed axial

tomography, computerized reconstruction tomography, computed topographic
scanning, axial tomography, computerized transaxial tomography. Currently, the
preferred name is computed tomography abbreviated as CT.

In its simplest form a CT scanner consists of a radiographic tube emitting a

finely collimated fan shaped X-ray beam directed to a series of scintillation detectors
or ionization chambers. Depending on the geometry of the scanner, both the
radiographic tube and the detectors may rotate synchronously about the patient or
the detectors may from a continuous ring about the patient and the X-ray tube may
move in circles within the detectors ring. Regardless of the mechanical geometry the
transmission signal is recorded by the characteristics of all elements of the patient in
the path of the X-ray beam.

The CT image is reconstructed by the computer which mathematically

manipulates the transmission data obtained from multiple projections. If one
projection is made every third of a degree than 1080 projections will result during

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the course of a single 360 degree rotation of the scanner about the patient. Data
derived from these 1080 projections (1080 projections=one scan) contain all the
information necessary to construct one image. The CT image is recorded and
displayed as a matrix is determined in parts by the computer program used to
construct the image; the length of the pixel (1 to 20) is determined by the width of X-
ray beam. It represents the absorption characteristics or linear attenuation
coefficient, of that particular volume of tissue with in the patient. CT number, also
known as Hounsfield units ranges from – 1000 to +1000, each constitutes a different
level of optical density. The scale of relative densities is based on air (-1000), water
(0), and dense bone (+1000).

Uses of CT

1) Due to high contrast resolution and ability to demonstrate small differences in

soft tissue dentistry, CT has become useful for the diagnosis of disease in the
maxillofacial complex including salivary glands and the temporomandibular
joint.
2) In Periodontics, the main use of CT is for the evaluation of the patient prior to
the placement of dental implants.
3) Recently, 3-D CT images are used for the preparation of the models which
may be further manipulated by rotation about any axis to display the images
structured from multiple angles. Additionally, external portion of the images
may be removed to reveal concealed deeper anatomy.
4.) CT technology is being continuously advanced. Recently, Imatron (San
Francisco) has introduced a CT scanner capable of acquiring data up to 10
times faster than conventional CT. It’s Ultrafast CT, is able to freeze cardiac
and pulmonary motion, enhancing the quality without motion artifacts.
Several other manufactures have developed spiral CT scanners. With these,
while the gantry containing the x-ray tube and detectors revolves around the
patient, the table on which the patient is laying continuously advances
through the gantry. This results in the acquisition of data as the x-ray beam

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moves down the patient. As compared to conventional CT scanners, it is

reported that spiral scanners provide for improvement multiplaner image
reconstruction, reduced examination time (12 seconds v/s. 5 minutes) and
reduced radiation dose (upto 75%).

OTHER RECENT TECHNIQUE

MAGNETIC RESONANCE IMAGING (MRI)

Magnetic resonance imaging uses non-ionizing radiations from the

radiofrequency band of the electromagnetic spectrum. To produce a magnetic
resonance image, the patient is placed inside a large magnet, which induces a
relatively strong external magnetic field. This causes the nuclei of many atoms in the
body, including hydrogen, to align them with magnetic field. After application of
radiofrequency signal, energy is released from the body, detected and used to
construct the magnetic resonance image on the computer. The high contrast
sensitivity of MRI to the tissue difference and the absence of the radiation exposure
are the reasons why MRI has replaced CT for imaging the soft tissues.
The theory of MRI is based on the magnetic properties of an atom. Atomic
nuclei spin about their axis as the earth spin about its axis. In addition, individual
proton and neutrons which make up the nuclei of the atom possess a spin or angular
momentum. In nuclei in which the protons and neutrons are evenly paired, the spin
of each nucleon cancels that of another, producing net spin of zero. In nuclei that
contains unpaired proton or neutron, a net spin is created, both the spins are
associated with the electric change, a magnetic field is generated in nuclei with
unpaired nucleons, causing these nuclei to act as magnets with north and south
poles.

As soon as, the radio waves (the resonant radiofrequency pulse) are turned off
two events occur simultaneously- the radiation of energy and the return of the nuclei

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to their original spin state at lower energy. The process is called relaxation, and the
energy loss is detected as a signal, which is called free induction delay (FID):
First, the nuclei in transverse alignment begin to realign themselves with the main
magnetic field and net magnetization re-grows to the original longitudinal
orientation. Relaxation is accomplished by transfer of energy from individual
hydrogen nuclei (spin) to surrounding molecule (lattic). The time constant that
describe the rate at which the net magnetization return to the equilibrium by this
transfer of energy is called the T1 relaxation time or spin lattice relaxation time.
A T1- weighted image is produced by a short replication time between the
radiofrequency pulse and the short signal recovery time.

Second, magnetic moment of adjacent hydrogen nuclei began to interfere with one
another, this causes the nuclei to diphase, with a resultant loss of transverse
magnetization. The time constant that describe the rate of loss of transverse
magnetization is called T2 relaxation time or transverse (spin-spin) relaxation time. T2
weight image is acquired using a long repetition time between radiofrequency pulse
and the long signal recovery time.

T2 weighting is most frequently used to demonstrate inflammatory or pathological

changes. T1 weighting weighted use to demonstrate anatomy.

MRI has several advantages over diagnostic imaging procedures are:

1) It offers best resolution of tissue of low inherited contrast.
2) No ionizing radiation is involved with the MRI.
3) Because the region of the body imaged in MRI is controlled electronically,
direct multiplanar imaging is possible without reorienting the patient
NUCLEAR MEDICINE

The technique of Nuclear medicine, also termed as bone scanning, is one of

the recent advances in the assessment of early changes in bone metabolism that my
precede the alternation in the osseous architecture during the course of the disease.

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Radionuclide imaging is based on radiotracer method which assumes radioactive

atoms or molecule in an organism, behaves in the manner identical to that of their
stable counterpart because they are chemically indistinguishable. Radiotracers allow
measurement of tissue function in vivo and provide an early marker of disease
through the measurement of biochemical change. Radionuclide- labeled tracers are
used in quantities well below amounts that are lethal to cells. However in spite of the
fact the radionucliotide imaging is considered noninvasive, the radiation dosage the
patient receive as a result of intravenous injection of radionucliotide-labeled tracer
should be considered.36

Many gamma emitting isotopes have been used in radionucliotide imaging,

including iodine (131I), gallium (67Ga), and selenium (74Se), one of the most commonly
used isotrope is technetium 99m (99mTC).

A stationary Anger camera or a rectilinear scanner is capable of producing a flat

plane image of an area or organ. Use of Anger camera with the capacity to rotate 360
degree about the patient or specialized ring detector makes single photon emission
computed tomography (SPECT) possible. In this technique, either multiple detectors
or a single moving detector allow acquisition of data from a number of contiguous
transaxial slices, similar to CT.

An even more recent development than SPECT in the field of nuclear medicine is
Positron Emission computed Tomography (PET). PET which is reported to have
sensitivity nearly 100 times that of gamma camera relies on positron-emitting
radioduclides generated in a cyclotron.

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