EO 005.06 Abnormal Radiographic Anatomy UNCLASSIFIED//REL TO NATO/ISAF

Radiographic Interpretation of Dental Caries

Severity of Caries Early, incipient Moderate Advanced and Extensive

Caries Progression

Location of Caries Occlusal, incisal Proximal Lingual, palatal Facial Cemental Recurrent

Incipient Caries

Incipient Caries

Occlusal Caries

Occlusal Caries

Occlusal Caries

Proximal Caries

Proximal Caries

Proximal Caries

Cemental Caries

Recurrent Caries Caries immediately next to a restoration Inadequate margins or excavation Pulpal necrosis Metallic restorations often hide Clinical examination

Recurrent Caries

Recurrent Caries

Caries: Xerostomia Therapeutic radiation Xerostomia Caries begins at cervical region

Occlusal Caries

Cervical Burnout

Adumbration

Adumbration Between CEJ and alveolar crest Diffuse radiolucency Ill-defined borders Presence of the edge of root Clinical evaluation

Adumbration

Rampant Caries

Rampant Caries

Caries associated with an impacted tooth

Periodontal And Periapical Diseases

Periodontal Disease

Usefulness of Radiographs Amount of bone present Condition of alveolar crest Bone loss in furcation areas Width of periodontal ligament Local factors: calculus, overhanging restorations Crown/root ratio

Limitations of Radiographs No indication of morphology of bony defects No indication of successful management No indication of hard/soft tissue relationship, i.e., depth of pockets

Normal Alveolar Crest 1.0-1.5 mm apical to cemento-enamel junction Parallel to line joining the CEJ of adjoining teeth Smooth Continuation of lamina dura, has the same radiopacity

Normal Alveolar Crest

Normal Alveolar Crest

Normal Alveolar Crest

Evidence of Early Periodontitis Localized erosion of crest of bone Blunting of crest- anterior teeth Loss of sharp angle between lamina dura and crest Widening of PDL near crest

Evidence of Early Periodontitis

Periodontitis radiograph evaluation

Local Factors Calculus Overhanging restorations Poor restoration contours

Calculus

Overhanging Restoration

Direction Of Bone Loss Horizontal Bone Loss: Crest of bone is parallel to CEJ line between adjoining teeth. The remaining bone is still horizontal but may be positioned apically.

Direction Of Bone Loss Vertical bone loss Crest of remaining bone is not parallel to the CEJ line between adjoining teeth (displays an oblique angulation to the CEJ line )

Bone Loss In furcation Areas

Bone Loss In furcation Areas

Bone Loss In furcation Areas

Bitewing Radiographs Most Reliable For Crestal Bone Evaluation

Periapical Lesions

Periapical Inflammatory Lesions Bone destruction around apex of tooth, mostly secondary to pulp exposure due to caries or trauma. Bacterial invasion of pulp produces toxic metabolites which escape to the periapical bone through apical foramen and cause inflammation.

Periapical Inflammatory Lesions Periapical granuloma: Localized mass of chronic granulation tissue containing PMN’s, lymphocytes, plasma cells.

Periapical Granuloma Radiographicall y, widening of PDL or variable size of periapical radiolucency may be present

Periapical Granuloma

Periapical Granuloma

Periapical Abscess Periapical abscess: When pus forms in the area. It may develop directly as an acute process or develop in a pre- existing granuloma. Radiographically, appears identical to granuloma.

Periapical Granuloma Or Abscess Can one differentiate between the two on the basis of radiographs alone?

Radicular cyst (periapical cyst): A cyst is an epithelium lined cavity which is filled with fluid or semi-solid material. Radicular cyst is the ONLY cyst related to non-vital pulp.

periapical cyst

periapical cyst

Periapical Inflammatory Lesions Can you definitively differentiate between a periapical granuloma, abscess or radicular cyst on the basis of radiograph alone?

Periapical Inflammatory Lesions

Periapical Inflammatory Lesions Sclerosing osteitis (chronic sclerosing osteomyelitis). Occasionally, the reaction to periapical inflammation is predominantly osteoblastic, i.e., more sclerotic bone is formed (radiopaque mass). Usually occurs in children or young adults when the resistance is high. Most common location is mandibular 1st molar.

Sclerosing Osteitis

(Idiopathic) Osteosclerosis

Osteosclerosis How do you differentiate between osteosclerosis and condensing osteitis? In osteosclerosis, the pulp is vital. There are no clinical signs or symptoms. No treatment is necessary. Sclerosing osteitis is secondary to pulp exposure. Patient is symptomatic. Endodontic treatment or extraction is indicated.

Calcific Degeneration Secondary to Trauma to the Tooth

Calcific Degeneration

Radiographic Evidence Of Non-vital Teeth Widening of apical PDL or periapical radiolucency ( associated with indication of pulp exposure) Discontinuity of lamina dura Displacement of lamina dura Sclerosing osteitis Calcific degeneration (metamorphosis) Radiographic indication of pulp exposure

Periapical Cemental Dysplasia Also called Cementoma. Localized alteration in periapical area. Osseous structure is replaced by fibrous tissue, cementum-like material, abnormal bone or combination of these. Pulp is vital. Patient is asymptomatic. There are no clinical signs. No treatment is required. Mean age is 39 years.

Periapical Cemental Dysplasia 85% patients are females. 3 times more common in African- americans. Most commonly seen in mandibular anterior areas. May be multiple. May be bilateral. Well-defined radiolucency, opacity or mixed.

Periapical Cemental Dysplasia

Apical Scar (Fibrous Scar ) Variation in healing process. Normally surgical site fills with blood clot which organizes and eventually mineralizes and remodels like surrounding bone. Occasionally, normal mineralization and remodeling fails to occur. Patient is asymptomatic and no treatment is required.

Fibrous Scar

Apical Scar (Fibrous Scar )

Apical Scar (Fibrous Scar )

Developmental anomalies of Teeth

Microdontia Smaller than average Most commonly involved: Maxillary 3rd molars Maxillary laterals (sometime called “peg” laterals) Maxillary premolars

Macrodontia (larger than normal) Tooth size larger than average Unknown cause May involve a single tooth or group of teeth Detectable by clinical examination

Gemination During development, single tooth germ attempts to divide into two. Usually results in bifurcation of a part of crown Unilateral or bilateral Normal complement of teeth is present

Gemination

Fusion During development, union of two adjoining tooth germs Clinically, identical to gemination, i.e, bifurcated crown One tooth is missing Unilateral or bilateral Primary or permanent dentition

Concrescence Union of two teeth either during development or after they are completely formed Joined with cementum Radiographic diagnosis can be difficult

Dilaceration Unusual angulation of roots Cause is either trauma to a developing tooth or unknown Diagnosed radiographically Surgical removal of dilacerated teeth can be difficult

Root Bifurcations

Dens Invaginatus (Dens-in-dente) Invagination of a layer of enamel and dentin into pulp. Creates a potential space for entrapment of food debris and bacteria. Wide variation in size. Clinically, either not discernible or seen as a prominent pit at the cingulum.

Dens Invaginatus (Dens-in-dente) Frequently, caries, pulp exposure and periapical pathology develops without any clinical indication. Most frequently (95%) in maxillary lateral incisor. Bilateral in half the cases. Prophylactic restoration recommended.

Dens Invaginatus (Dens-in-dente)

Dens Evaginatus Due to outfolding of an enamel organ Usually on the occlusal surface of a premolar or a molar The outgrowth is covered with enamel, dentin and contains pulp Detectable clinically

Talon cusp

Taurodontia Bifurcation of molar pulp chamber into root canals displaced apically, resulting in an extremely large pulp chamber and short root canals. Usually in permanent molars. Most patients asymptomatic; does not require treatment. Frequently, bilateral.

Taurodontia

Localized Enamel Hypoplasia- Miscellaneous Causes Local or systemic disturbances during development of permanent teeth. Examples: nutritional disturbances, childhood infections, etc. Usually affect permanent anterior teeth and first molars bilaterally.

Localized Enamel Hypoplasia- Miscellaneous Causes

Localized Enamel Hypoplasia- Miscellaneous Causes

Localized Enamel Hypoplasia- Congenital Syphilis Affects permanent incisor or 1st molar Affected incisor is named Hutchinson’s incisor; 1st molar is named mulberry molar

Localized Enamel Hypoplasia- Congenital Syphilis

Anomalies of Tooth Number Hypodontia: Few missing teeth Oligodontia: More than half the number missing in any dentition (permanent or primary) Anodontia: All teeth missing

Hypodontia Frequency of congenitally missing permanent teeth, in the following order: 3rd molars Maxillary 2nd premolars Mandibular 2nd premolars Maxillary laterals Mandibular canines Other

Hypodontia

Hypodontia

Supernumerary (Hyperdontia) 80-85% of all supernumerary in maxilla Mesiodens. Midline of maxilla. 85-90% Paramolars. Buccal or lingual to maxillary molars Distomolars (4th molars, distodens). Distal to maxillary 3rd molars

Mesiodens

Mesiodens

Paramolar

Distodens

Supernumerary premolars

Impacted Canines

Supernumerary Roots

Regressive Changes of Teeth Attrition Abrasion Erosion

Attrition Physiologic wearing away Incisal, occlusal and interproximal surfaces Part of aging process Bruxism – pathologic attrition

Attrition – Radiologic Features Change in normal outline Flat occlusal plane Loss of mamelon Pulp chamber, canal size diminuish Hypercementosis

Attrition

Attrition

Abrasion Non-physiologic wearing away Habits Toothbrush trauma Dental floss injury Occupational hazards

Abrasion – Radiologic Features Radiolucent defects at the cervical region Well-defined semilunar defects Pulp chambers sclerosed In case of dental floss injury, distal surfaces more involved

Abrasion

Erosion Chemical cause No bacteria involved Diet: Labial surfaces are affected Regurgitation: Lingual surfaces are affected Occupational hazards

Erosion

Resorption Phenomenon External Internal

External Resorption Pathological Inflammation: Trauma, Chronic Apical Periodontitis Infection Cysts: OKC Benign and malignant neoplasm

External Resorption Non pathological Mechanical force: orthodontic tooth movement Idiopathic Impacted teeth

External Resorption Trauma Periapical Path

External Resorption: Orthodontic

Ext. Resorption: Tumors/cysts

Ext. Resorption: Tumors/cysts

External Resorption

External Resorption: Idiopathic

Internal Resorption Trauma Idiopathic

Internal Resorption

Dental Trauma

Dental Trauma Coronal fracture Root fracture Alveolar fracture

Fracture: Crown

Fracture: Crown, Root

Fracture: Root

Vertical Fracture: Root

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