DATE : 17/05/2016

Radiographic Aids In Diagnosis of

Periodontal Diseases Part A

DR. IBRAHIM SHAIKH

MDS III

DEPT. OF PERIODONTOLOGY & IMPLANTOLOGY

SEMINAR NO. - 8

CONTENTS
Introduction.
History.
Radiographs.
Interpretation of radiological examination.
Interpretation in relation to periodontal
diseases.
6. Advances in radiographs.
7. Limitations of radiographs.
8. Implant imaging (Briefly).
9. Conclusion.
10.References.
1.
2.
3.
4.
5.

Introduction

History

HISTORY
Discovery of X-Rays - November 8

th

, 1895

Wilhelm Conrad Roentgen

(1845 1923)
5

Forms of tube used by Roentgen in 18951896 for the

production of X rays.

HISTORY
First Dental Radiograph 12

th

January, 1896

Dr. Otto Walkof

(1860 1934)
6

HISTORY
First Intraoral Dental Radiograph Early 1896

Dr. Edmund Kells

(1856 1928)
7

HISTORY
First Intraoral Dental Radiograph Early 1896

Radiographs

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
10
Root length and shape(s) remaining in bone

11

RADIOGRAPH
S

INTRA ORAL

EXTRA ORAL

IOPA,
BITEWINGS
& OCCLUSAL

OPGS
12

Paralleling technique

Intra Oral Periapical

Radiographs

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.

13

Intra Oral Periapical

Radiographs

Bisecting angle technique

Central ray is directed at right angles to a plane

bisecting the angle between long axis of teeth &
film.
Makes the bone margin appear more closer to the
crown.

14

Extra Oral Periapical

Radiographs

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

15

Chen et al in 2007

Extra Oral Periapical

Radiographs

Developed a sensor beam alignment aiming device for

performing radiographs using this technique

16

Bitewing Radiographs
Records the coronal part of upper & lower dentition along
with periodontium.
Uses:
To study height & contour of interdental alveolar
bone.
To detect interproximal calculus.
To detect periodontal changes

17

Bitewing Radiographs
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.

18

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

19

Extraoral Radiographs
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.

20

Orthopantomograph
Technique for producing single tomographic image of
facial structures including maxillary and mandibular
arches with their supporting structures.
Based on principle of the reciprocal movement of x-ray
source and image receptor around a central plane
known as image layer.

21

Orthopantomograph
Limitations of OPG
Image distortion
Lingual structures would be projected higher than
buccal surfaces
Less details than intraoral images
Production of ghost images

It can be used as a
alternative for intra oral
full mouth series when
combined with bite wing
radiographs

22

Tugnait et al. 2000,2005

The
periodontal structures of interest
noted on
periapical radiographs are also noted on panoramic
radiographs.
The radiographic features of interest on a panoramic
radiograph supplemented when necessary by a small
number of intra-oral views, is sufficient
for the
management of periodontal diseases

Pepallasi EA et al. 2000

Panoramic radiographs may not reveal alveolar bony

defects as accurately as periapical radiographs.
But question is whether there is any additional
therapeutic yield from greater accuracy from IOPAs
23

Vazquez et al 2007

Determined the efficacy of panoramic

radiographs in the preoperative planning
of posterior mandibular implants .

Mental nerve parasthesia - following

implant placement in 1527 patients with
2584 implants with only OPGs as
preoperative imaging technique.
No permanent sensory disturbances of the
inferior alveolar nerve.
Only 2 cases i.e.
paraesthesia.

0.08 % reported

Panoramic
examination
is
preoperative evaluation tool.

safe
24

Digital Radiography
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 e.g. density & contrast can be
lowered for evaluation of marginal bone and increased
for
evaluation
of
implant
components.

Enables the
consultations.

dental

team

to

conduct

remote

Computerized images can be stored, manipulated &

25
corrected for under & overexposure

Radiovisiography
Duret F et al 1988
Based on use of Charged Couple Device.
Radio X-ray generator connected to sensor.
Visio storage of incoming signals during exposure and
conversion to grey levels.
Graphy digital mass storage unit connected to various
video printout devices.

26

Radiovisiography
Mechanism of Image Display
Radiographic digital
detector
Conventional
radiographic source
used to expose sensor
Detector converts Xrays to visible image

Image display on
monitor

27

Mouyen F et al 1989
The RVG system when compared with conventional
uses considerably reduced levels
of radiation to
produce an image immediately after exposure.

Adosh L in 1997
Comparative study for marginal bone between RVG
and after surgical exploration
Presented that Majority showed difference of less than
0.5 mm between two techniques
28

A.R. Talaiepour et al in 2005

Evaluated the accuracy of RadioVisioGraphy (RVG) in the
linear measurement of interproximal bone loss in intrabony
defects.

Comparison between RVG measures and intrasurgical

estimates were performed in 56 teeth with intrabony
defects.

The
radiographic
measurements
overestimated
interproximal bone loss as compared to the intrasurgical
measurements.

29

Digital Subtraction Radiography

Zeidses des Plantes 1935
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
Darker area represents loss
30

Base Line
Bone Gain
Ortmann 1994
5% of bone
detected.

After One Year

loss

can

be

Diagnostic
subtraction
radiography (DSR) can be used
for
enhanced
detection
of
crestal
or
periapical
bone
density changes and to evaluate

31

Standardization

Baseline projection geometry and image density should

be reproduced
bite blocks must be made and attached to the film
holders and the film holder must be reproducibly
aligned to the x-ray beam collimating device

32

ADVANTAGES
DISADVANTAGES
Overall contrast is
improved
Trabecular marrow spaces No objective description.
are visualized
High standardization of x
Enhancement of low and rays.
high density images
No reduction in exposure .

33

Extra Oral Digital Imaging

34

Conventional Tomography
Godfrey Hounsfield and Allan
MacLeod Cormack 1979
Designed to image a slice or plane of tissue
Accomplished by blurring the images lying outside the
plane of interest
It consists of an x ray tube and radiographic film rigidly
connected which moves about a fixed axis and fulcrum
As exposure begins, the tube
circumferentially simultaneously .
Objects located with in the fulcrum
positions and are viewed clearly.

and

film

move

remain in fixed
35

36

Conventional Tomography
CT Image Construction

Computer algorithms use photon counts to construct

digital CS images
Images are displayed in individual blocks ----- VOXELS
Each square of the image is matrix ---- PIXELS
Each pixel is assigned a CT number representing tissue
density

CT number
Range

HOUNSFIELD units
-1000 to 1000
37

Conventional Tomography
Advantages
Eliminates superimposition of images of structures
outside area of interest
High contrast resolution differences between tissues
that differ in density < 1% - can be distinguished
Images can be viewed in axial coronal and sagittal
planes

38

Naito T et al. 1998;

Pistorius A et al. 2001
Used Computed tomography (CT)
periodontal defects.

in studies in relation to

CT does not offer any favourable cost benefit, dose

exposure or therapeutic yield advantage in periodontal
practice and is unlikely to find a routine.

39

Cone Beam Computed

Tomogrphy
Utilizes cone shaped source of ionizing radiation & 2D
area detector fixed on a rotating gantry.
Multiple sequential images are produced in one scan.
Rotates 360 around the head.
Scan time typically < 1 minute.

40

Cone Beam Computed

Tomogrphy

INTERFACE CONE-BEAM CT MANAGEMENT

SOFTWARE

41

Indications

Cone Beam Computed

Tomogrphy

Evaluation of the jaw bones.

Implant placement and evaluation.
Evaluation TMJ.
Bony & Soft tissue lesions.
Periodontal assessment.
Endodontic assessment.
Alveolar ridge resorption.
Orthodontic evaluation.
3D reconstructions.
42

PANORAMIC

CBCT

Superimposition

Separated structures

Only one layer view

CS, Axial, Coronal

Sagittal views

Distorted images

Undistorted

43

CT V/S CBCT
Conventional CT scanners
make use of a fan-beam and
Provides a set of
consecutive slices of
image.

Utilize a cone beam, which

radiates from the x-ray

source in a cone shape,
encompassing a large
volume with a single
rotation.

Conventional CT makes use

of a lie-down machine with
a large gantry.

A sitting-up machine of
smaller dimensions

Greater contrast &

resolution.

Commonly used for hard

tissue.

More discrimination
between different tissue
types (i.e. bone, teeth, and
soft tissue)

Ease of operation.
Dedicated to dental.

44

CT V/S CBCT

Artefacts arising from metal

restorations are more
severe using conventional
CT.

Artefacts that arise from

metallic restorations are less
severe.

45

Kelly A. Misch et al . 2006

Compared radiographs with CBCT
Results: Three-dimensional capability of CBCT offers a
significant advantage in linear measurements for
periodontal defect
All defects can be detected and quantified.

Mol A and Balasundaram 2008

Evaluated The NewTom 9000 CBCT scanner
Results: Better diagnostic and quantitative information
on periodontal bone levels in three dimensions than
conventional radiography can be obtained

46

Brently A. et al 2009
Compared the measurements from digital IR and CBCT
images to direct surgical measurements for the
evaluation of regenerative treatment outcomes.
Compared to direct surgical measurements, CBVT
significantly more precise and accurate than IRs.
CBVT may obviate surgical re-entry as a technique for
assessing regenerative therapy outcomes

Walter C et al. 2011

Suggests that cone-beam CT
may
provide
detailed
information
about
furcation
involvements in patients with
chronic periodontitis and so
may
influence
treatment

47

Interpretation of Radiographs

48

Interpretation of Radiographs
Basic Prerequisites
Detailed understanding of three dimensional anatomy
and how structures appear radiologically.
Know the differences in radiologic anatomy in a 2D & a
3D radiograph.
Must possess knowledge of diseases which are
potentially assosciated with all structures in the FOV.
Must be aware and knowledgable of all different
imaging modalities.
Optimal viewing conditions are essential.
49

Interpretation of Radiographs
Key Steps in Interpretation
Recognizing the presence of an abnormality.
Radiologic evaluation of a lesion
o Location.
o Shape and Contour.
o Border.
o Internal appearances.
Adjacent anatomic structures
Interpretation of the findings.

50

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
51

6. Bragger U: Digital Imaging In Periodontal Radiography-

PART B
1. Interpretation in relation to periodontal
diseases.
2. Advances in radiographs.
3. Limitations of radiographs.
4. Implant imaging (Briefly).
5. Conclusion.
6. References.

52

THANK YOU
Next Presentation On
Thursday 19/05/2016
Journal Club Presentation By
1.Dr. Leena Parmar
2.Dr. Reshma Avadh

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