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USES OF RADIOGRAPHS IN

ORAL SURGERY
Dept of Oral and Maxillofacial Surgery
IIDC, Islamabad
DEFINITIONS

 RADIATION:
Emission of energy in the form of EMR or particulate
radiation

 RADIOGRAPHY:
The techniques involved in producing radiographs

 RADIOLOGY:
Interpretation of radiographs and other images
PROPERTIES OF XRAYS
 Invisible
 Have no charge
 Travel at the speed of light
 Have no mass or weight
 Travel in straight lines
 Can cause ionization
 Can effect photographic film emulsion
 Can effect living tissue
 Can penetrate opaque tissues and structures
CONVENTIONAL RADIOGRAPHY

 Conventional radiography uses radiographic film


as the image detector/sensor
DIGITAL IMAGING

 Digital imaging uses a charged coupled device


(CCD) as the image detector/sensor
ADVANTAGES OF DIGITAL IMAGING

 No use of films, intensifying screens, cassettes,


etc.
 Computer hardware and software allows you to
view and store images
 Multiple images are obtained without changing
film holder or using new film
 Less exposure to radiation
ROLE OF RADIOGRAPHS

 Clinical examination phase


 Diagnosis (confirm/exclude)
 Treatment planning
 During treatment
 Follow up after various treatment procedures
BIOLOGICAL EFFECTS OF RADIOGRAPHS

 Somatic DETERMINISTIC effects:


Damaging effects to the body of the person exposed that will
definitely result from a specific high dose of radiation e.g.,
skin reddening and cataract formation

 Somatic STOCHASTIC effects:


Damaging effects may be induced when the body is exposed
to any dose of radiation e.g., leukemia and certain tumors

 Genetic STOCHASTIC effects:


Mutations result from any sudden change to a gene or
chromosome. Can be caused by external factors, such as
radiation or occur spontaneously
BIOLOGICAL EFFECTS OF RADIOGRAPHS

 EFFECTS ON THE UNBORN CHILD:


Developing fetus is particularly sensitive to the
effects of radiation, especially during the period of
organogenesis (2-9 weeks after conception). The
major problems are:
1. Congenital abnormalities or death due to large
doses of radiation
2. Mental retardation associated with low doses of
radiation
TYPES OF ORAL RADIOGRAPHS

 Intraoral

 Extraoral

 Other technologies/imaging modalities


INTRAORAL RADIOGRAPHY

 Radiographic film/detector is exposed whilst


inside the patient’s mouth
 Image of a small area – a few teeth and adjacent
supporting structures, is obtained
INTRAORAL FILMS

 Coated on both sides allowing less radiations to


make an image
 Corner of film has a raised dot
 Convex part of the dot is towards the tube and
concave towards the patient tongue
 Concave part is kept towards the operator
 Film enveloped in paper on both sides
 Lead shield on back of the film which protects
the film from secondary radiations
TYPES OF INTRAORAL RADIOGRAPHS

 Intraoral radiographs can be divided into


3 categories:
1. Periapical radiographs
2. Bitewing radiographs
3. Occlusal radiographs
PERIAPICAL PROJECTIONS
PERIAPICAL PROJECTIONS
 These radiographs show all of a tooth, including the
surrounding bone
 INDICATIONS:
 Detection of apical infection/inflammation
 Dental trauma (to the tooth and associated alveolar bone)
 Assessment of the presence and position of unerupted teeth
 Assessment of root morphology before extractions
 Endodontic diagnosis, planning, treatment and monitoring
 Detailed evaluation of apical cysts and other lesions within the
alveolar bone
 Evaluation of implants postoperatively
Radiographic techniques
 Two techniques for periapical radiography have been
developed:

1. The paralleling technique:


the film is positioned in
the mouth parallel to the
long axis of the tooth
and x-ray tube aimed at
right angles
Radiographic techniques
2. The bisected angle technique:
film is placed as close to the
tooth as possible without
bending, angle between film
and tooth bisected, x-ray
tube positioned at right
angles to this bisected line
BITEWING PROJECTIONS
BITEWING PROJECTIONS
 These radiographs show only the crowns of maxillary and
mandibular teeth and adjacent alveolar crests
 Film has a flap opposite its center upon which the patient
bites to occlude upper and lower teeth
 INDICATIONS:
 Baseline examination
 Detection of:
 Dental caries
 Non carious tooth loss
 Monitoring the progress of any loss of tooth structure
 Assessing existing restorations (defects, contacts)
 Assessment of periodontal status
OCCLUSAL PROJECTIONS

 These radiographs show an area of teeth and


bone larger than periapical radiographs
 Occlusal film is held in position by letting the
patient bite lightly on the film to support it
between the occlusal surface of each jaw
 Divided into:
 Upper occlusals
 Lower occlusals
OCCLUSAL PROJECTIONS
UPPER OCCLUSALS
OCCLUSAL PROJECTIONS

 INDICATIONS:
 Presence/absence of developing teeth, supernumerary teeth,
impacted teeth
 Evaluation of the size and extent of lesions (cysts or tumors) in
maxilla
 For determining bucco/palatal position of unerupted canines
 Assessment of the condition of antral floor
 As an aid to determine position of roots displaced into the antrum
during attempted extraction of upper posterior teeth
 Assessment of fractures of teeth and alveloar bone including
tuberosity
 Localization technique (used with another film)
 When unable to take intraoral radiographs
 Limited mouth opening
 Uncooperative child
OCCLUSAL PROJECTIONS
LOWER OCCLUSALS
OCCLUSAL RADIOGRAPHY
 INDICATIONS:
 Detection of the presence and position of radiopaque calculi
in the submandibular salivary ducts
 Assessment of the bucco-lingual position of unerupted
mandibular teeth
 Evaluation of the bucco-lingual expansion of the mandible by
cysts, tumors or dystrophies
 Assessment of displacement fractures of mandible in the
horizontal and vertical plane
 Periapical assessment of lower incisor teeth, especially useful
in adults and children unable to tolerate periapical films
EXTRAORAL RADIOGRAPHY

 Radiographic film/detector positioned outside


the patient’s mouth
 Can take images of larger areas of mandible,
maxilla, face and skull
TYPES OF EXTRAORAL RADIOGRAPHY

 Extraoral radiography includes:


1. Skull radiography:
 Lateral cephalometric projection (of sagittal or median
plane)
 True Lateral skull
 Submentovertex projection (of transverse or horizontal
plane)
 The Water’s projection (coronal or frontal plane)
 Posteroanterior cephalometric projection (coronal or frontal
plane)
 Posteroanterior projections of the jaws
 Reverse-Towne projections (coronal or frontal plane)
TYPES OF EXTRAORAL RADIOGRAPHY

2. Oblique lateral projections of the mandibular


body and ramus
3. Tomography
4. Panoramic radiograph
 Orthopantomograph (OPG)
 TMJ
 PNS
Lateral cephalometric projection
Lateral cephalometric projection

 INDICATIONS:
 Orthodontics
 Orthognathic surgery:
1. Preoperative evaluation of skeletal and soft tissue
patterns
2. To assist in treatment planning
3. Postoperative appraisal of the results of surgery and long
term follow up studies
True lateral skull view
 INDICATIONS:
 Fractures of the cranium and the cranial base
 Middle third facial fractures to show possible downward and
backward displacement of the maxillae
 Investigation of the frontal, sphenoidal and maxillary sinuses
 Conditions affecting the skull vault, particularly
 Paget’s disease
 Multiple myeloma
 Hyperparathyroidism
 Conditions affecting the sella turcica such as,
 Tumors of the pituitary gland and acromegaly
Submentovertex projection (Jug handle
view)
Submentovertex projection (Jug handle
view)
Submentovertex (SMV)

 INDICATIONS:
 Destructive/expansive lesions affecting the palate,
pterygoid region or base of skull
 Investigation of the sphenoidal sinus
 Assessment of the thickness of the posterior part of
the mandible before osteotomy
 Fracture of the zygomatic arches – to show these thin
bones the SMV is taken with reduced exposure
factors
Occipitomental (Water’s) view
Occipitomental (Water’s) view
Occipitomental (Water’s) view
 INDICATIONS:
 Investigation of the maxillary antra
 Investigation of the frontal and ethmoidal sinuses
 Investigation of the sphenoidal sinus
 Detecting the following middle-third facial fractures:
 Le-Fort I
 Le Fort II
 Le Fort III
 Zygomatic Complex
 Naso-ethmoidal complex
 Orbital blow-out
 Coronoid process fractures
Postero-anterior Skull (Caldwell) view
Postero-anterior Skull (Caldwell) view

 INDICATIONS:
 Fractures of the skull vault
 Investigation of the frontal sinuses
 Conditions affecting the cranium, particularly,
 Paget’s disease
 Multiple myeloma
 Hyperparathyroidism

 Intracranial calcifications
Postero-anterior jaws view
Postero-anterior jaws view
 INDICATIONS:
 Fractures of the mandible involving:
 Posterior third of the body
 Angles
 Rami
 Low condylar necks
 Lesions such as cysts or tumors in the posterior
third of the body or rami
 Mandibular hypoplasia or hyperplasia
 Maxillofacial deformities
Reverse Towne’s projections
Reverse Towne’s projections

 INDICATIONS:
 High fractures of the condylar necks
 Intracapsular fractures of the TMJ
 Investigations of the quality of the articular surfaces
of the condylar heads in TMJ disorders
 Condylar hypoplasia or hyperplasia
Oblique lateral projections
Oblique lateral projections
 INDICATIONS:
 Assessment of the presence and/or position of
unerupted teeth
 Detection of fractures of the mandible
 Evaluation of lesions or conditions affecting the jaws
including cysts, tumors, giant cell lesions, and
osteodystrophies
 As an alternative when intraoral views are
unobtainable because of severe gagging or if the
patient is unable to open mouth or is unconscious
 As specific views of salivary glands or TMJ
TOMOGRAPHY

“It is a specialized technique


for producing radiographs
showing only a section or
slice of a patient”
TOMOGRAPHY
Lateral tomogram of TMJ in
closed position

1: External auditory canal


2: Superior border of
mandibular fossa of temporal
bone
3: Superior joint space
4: Squamo-tympanic fissure
5: Mandibular condyle
6: Articular eminence
TOMOGRAPHY
 Lateral tomogram of
TMJ in open position
 Extent of opening is
Within normal range

1. Superior border of
mandibular fossa
2. Articular eminence
TOMOGRAPHY
 Frontal (AP) tomogram
of condyle

1. Articular eminence
2. Medial pole of condyle
3. Superior border of
condyle
TOMOGRAPHY
 INDICATIONS:
 Assessment of jaw height, thickness and texture before
inserting implants
 Postoperative evaluation of implants
 Assessment of the size, position and extent of antral tumors
 Evaluation of grossly comminuted facial fractures to
determine all the fracture sites
 Assessment of the extent of orbital blow-out fractures
 As an additional investigation of the TMJ and condylar head –
particularly useful if patients are unable to open their mouths
 In conjunction with arthrography of the TMJ
PANORAMIC RADIOGRAPHS
ORTHOPANTOMOGRAM (OPG)
PANORAMIC RADIOGRAPHS
ORTHOPANTOMOGRAM (OPG)
PANORAMIC RADIOGRAPHS
ORTHOPANTOMOGRAM (OPG)
PANORAMIC RADIOGRAPHS
 INDICATIONS:
 As part of orthodontic assessment where there is
clinical need to know the state of the dentition and
presence/absence of teeth
 To assess bony lesions or an unerupted tooth
 Prior to dental surgery under general anesthesia
 As part of an assessment of periodontal bone
support where there is pocketing greater than 5mm
 Assessment of third molars, at a time when
consideration needs to be given to whether they
should be removed or not
PANORAMIC RADIOGRAPHS
TMJ PANORAMIC
PANORAMIC RADIOGRAPHS
 INDICATIONS:
In addition dental panoramic radiographs are
also used to assess:
 Fractures of all parts of the mandible except the
anterior region
 Antral disease – particularly to the floor, posterior
and medial walls of the antra
 Destructive diseases of the articular surfaces of the
TMJ
 Vertical alveolar bone height as part of pre-implant
planning
INDICATIONS OF TRADITIONAL OPG

 Assessment of
 Wisdom teeth
 TMJ pathology
 Maxillary sinus
 Jaw bone pathologies
 Orthodontic diagnosis
 Jaw bone fractures
OTHER TECHNOLOGIES AND IMAGING
MODALITIES
 Contrast studies
 Radioisotope imaging
 Computerised tomography (CT)
 Magnetic resonance imaging (MRI)
 Ultrasound
 CT Angiography
Contrast studies

 These investigations use contrast media,


radiopaque substances that have been
developed to alter artificially the dentistry of
different parts of the patient, so altering subject
contrast – the difference in the x-ray beam
transmitted through different parts of the
patient’s tissues
Contrast studies

 Contrast studies include:


 Sialography – salivary glands
 Arthrography – joints
 Angiography – Blood vessels
 Lymphography – lymph nodes and vessels
 Etc.
SIALOGRAPHY
Radioisotope imaging

 It relies upon altering the patient by making the


tissues radioactive and the patient becoming the
source of ionizing radiation
 The radioactive compounds become
concentrated in the target tissue and their
radiation emissions are then detected and
imaged, using a stationary gamma camera
Radioisotope imaging
 INDICATIONS:
 Tumor staging – the assessment of sites and extent
of bone metastases
 Investigation of salivary gland function, particularly in
Sjögren’s syndrome
 Evaluation of bone grafts
 Assessment of continued growth in condylar
hyperplasia
 Investigation of the thyroid
 Brain scans and assessment of a breakdown of the
blood-brain barrier
Computerized tomography (CT)

 Radiographic cutting of a region/structure into


thin slices
 Fairly high doses
 Good diagnostic information
 Used in oral maxillofacial surgery in:
 Diagnosis and treatment planning of tumors,
fractures and neuropathies
COMPUTERIZED TOMOGRAPHY (CT)
COMPUTERIZED TOMOGRAPHY (CT)
MAGNETIC RESONANCE IMAGING (MRI)

 Gives better soft tissue images than CT scans


 No radiation – uses magnetic field and sound waves
 Very good diagnostic information
 Used in oral maxillofacial surgery in:
 Diagnosis and treatment planning of tumors, fractures and
neuropathies
 Implant assessment
 Investigations of TMJ to show marrow changes and soft tissue
components of the joint including the disk
 Gold standard for TMJ imaging
MAGNETIC RESONANCE IMAGING (MRI)
ULTRASOUND

 Limited uses for dental care


 Salivary gland tumors
 Possibly TMJ
 Locating foreign objects in soft tissue
 Soft tissue cysts
CT ANGIOGRAPHY (CTA)

 Relatively new imaging modality


 It enables the display of vascular structures aided
by injections of contrast medium
 Image post processing enables good display of
the entire vascular system
 Even small vascular exits and origins (branches)
and embolisms or dissection membranes can be
displayed
REFERENCES
 Oral radiology – principles and interpretation; 5th
edition; White, Pharoah
 Essentials of dental radiography and radiology; 3rd
edition; Eric Whaites
 Textbook of Dental and maxillofacial radiology; 2nd
edition; Freny R Karjodkar
 Principles of Dental Imaging; 2nd edition; Olaf E
Langland, Robert P Langlais, John W Preece
THANKYOU 