1. Interpretation of Trauma and Pulpal and Periapical Lesions
Chapter 35
Interpretation of Trauma and Pulpal and Periapical Lesions

2. Dental Radiography Questions
What changes resulting from trauma or resorption may be observed on dental images?
What features of pulpal lesions or periapical lesions may be observed on dental images?
What is the appearance of crown, root, and/or jaw fractures on dental images?

3. Dental Radiography Chapter 35 Reading
Iannucci & Howerton (pp )

4. Dental Radiography Chapter 35 Outline
Interpretation of Trauma and Pulpal and Periapical Lesions
Trauma viewed on dental images
Resorption viewed on dental images
Pulpal lesions viewed on dental images
Periapical lesions viewed on dental images

5. Introduction Purpose Iannucci & Howerton (pp. 426)
To provide a brief overview of the common features of trauma and pulpal and periapical lesions as viewed on dental images

6. Trauma Viewed on Dental Images
Fractures
Injuries

7. Trauma Viewed on Dental Images
Iannucci & Howerton (pp )
Trauma
Trauma is an injury produced by an external force.
It may affect the crowns and roots of teeth as well as alveolar bone.
It may result in injuries of teeth and bone and injuries such as intrusion, extrusion, and avulsion.

8. Fractures The breaking of a part Iannucci & Howerton (p. 427)
May affect the crowns and roots of teeth or the bones of the maxilla or mandible
Includes
Crown fractures
Root fractures
Jaw fractures
Whenever a fracture is evident or suspected, image examination of the injured area is necessary.

9. Crown Fractures This most often involves anterior teeth.
Iannucci & Howerton (p. 427) (Fig. 35-1)
This most often involves anterior teeth.
May involve enamel, dentin, and/or pulp.
The dental image permits evaluation of the proximity of the damage to the pulp chamber and for evaluation of the root for any additional fractures.
Most crown fractures result from an accident involving a fall or a motor vehicle.

10. Root Fractures
Iannucci & Howerton (p. 427) (Fig. 35-2)
Root fractures most often occur in the maxillary central region.
They may be vertical or horizontal, single or multiple.
If the x-ray beam is parallel to the plane of the fracture, it will appear as a radiolucent line.
If the x-ray beam is not parallel to the plane of the fracture, it may not be apparent at all.
Less common than crown fractures.
Result from an accident or traumatic blow.
With time, root fractures have a tendency to enlarge because of displacement of root fragments, hemorrhage, or edema.

11. Jaw Fractures Jaw fractures are most often observed in the mandible.
Iannucci & Howerton (pp ) (Fig. 35-3)
Jaw fractures are most often observed in the mandible.
The panoramic image is the best film for visualizing mandibular fractures.
On a dental image, the fracture appears as a radiolucent line.
Maxillary fractures are typically difficult to detect on dental images.
Frequently result from assaults, accidents, and sports injuries.
Maxillary fractures occur less frequently and most often involve the anterior alveolar bone and teeth.

12. Injuries Trauma may cause the displacement of teeth.
Iannucci & Howerton (pp )
Trauma may cause the displacement of teeth.
Displacement involves luxation and avulsion.

13. Luxation Luxation is the abnormal displacement of teeth.
Iannucci & Howerton (p. 428) (Figs. 35-4, 35-5)
Luxation is the abnormal displacement of teeth.
Intrusion is the abnormal displacement of teeth into bone.
Extrusion is the abnormal displacement of teeth out of bone.
Teeth that have been luxated should be evaluated by a periapical image and examined for root and adjacent alveolar bone fractures, damage to the periodontal ligament, and pulpal problems.

14. Avulsion
Iannucci & Howerton (p. 428) (Fig. 35-6)
Avulsion is the complete displacement of a tooth from alveolar bone.
The periapical image shows a tooth socket without a tooth .
Result from trauma associated with an assault or accidental fall.
Dental images are important in the evaluation of the socket areas and should be used to examine the region for splintered bone.

15. Resorption Viewed on Dental Images
External Resorption
Internal Resorption

16. Resorption Viewed on Dental Images
Iannucci & Howerton (pp ) (Fig. 35-7)
Physiologic resorption
A process seen with the normal shedding of primary teeth
Pathologic resorption
A regressive alteration of tooth structure observed when a tooth is subjected to abnormal stimuli
May be
External resorption
Internal resorption
The primary tooth is shed when resorption of the roots is complete.

17. External Resorption Seen along the periphery of the root surface
Iannucci & Howerton (p. 429) (Fig. 35-8)
Seen along the periphery of the root surface
This is often associated with reimplanted teeth, abnormal mechanical forces, trauma, chronic inflammation, tumors and cysts, impacted teeth, or idiopathic causes.
It most often involves the apices of teeth.
The apical region appears blunted.
The length of the root is shorter than normal.
Both the lamina dura and the bone around the blunted apex appear normal.
Not detected clinically and does not exhibit mobility.
No effective treatment.

18. Internal Resorption
Iannucci & Howerton (pp ) (Figs. 35-9, 35-10)
Internal resorption occurs within the crown or root of a tooth.
Involves the pulp chamber, pulp canals, and surrounding dentin.
It is believed to be precipitated by factors such as trauma, pulp capping, and pulp polyps.
It appears as a round-to-ovoid radiolucency in the midcrown or midroot portion of the tooth.
Endodontic therapy is recommended if perforation has not occurred.
Generally asymptomatic.
Treatment is variable.
If the tooth is weakened by the resorptive process, extraction is recommended.

19. Pulpal Lesions Viewed on Dental Images
Iannucci & Howerton (p. 429)
Examination of the pulp chambers and canals is impossible without dental images.
Dental images may detect conditions such as
Pulpal Sclerosis
Pulpal Obliteration
Pulp Stones

20. Pulpal Sclerosis
Iannucci & Howerton (pp ) (Fig )
Pulpal sclerosis is diffuse calcification of the pulp chamber and pulp canals of teeth.
Results in a pulp cavity of reduced size.
Is associated with aging.
It is of little clinical significance unless endodontic therapy is indicated.

21. Pulpal Obliteration
Iannucci & Howerton (p. 430) (Fig )
The production of secondary dentin may obliterate the pulp chamber.
These teeth are nonvital and do not require treatment.
May be caused from attrition, abrasion, caries, dental restorations, trauma, or abnormal mechanical forces.
Tooth does not appear to have a pulp chamber or pulp canals.

22. Pulp Stones
Iannucci & Howerton (pp ) (Figs , 35-14)
Pulp stones are calcifications found in the pulp chamber or pulp canals.
They appear on dental images as round, ovoid, or cylindrical radiopacities.
They may vary in shape, size, and number.
They do not cause symptoms.
They do not require treatment.

23. Periapical Lesions Viewed on Dental Images
Periapical Radiolucencies
Periapical granuloma
Periapical cyst
Periapical abscess
Periapical Radiopacities
Condensing osteitis
Sclerotic bone
Hypercementosis

24. Periapical Lesions Viewed on Dental Images
Iannucci & Howerton (pp )
A periapical lesion is located around the apex of a tooth.
It may appear either radiolucent or radiopaque.

25. Periapical Radiolucencies
Periapical granulomas, cysts, and abscesses are commonly seen on dental images.
These lesions cannot be diagnosed on their dental image appearance alone.
Diagnosis is based on clinical features and dental image and microscopic appearance.

26. Periapical Granuloma
Iannucci & Howerton (pp ) (Figs , 35-16)
This is a localized mass of chronically inflamed granulation tissue at the apex of a nonvital tooth.
It is the most common sequela of pulpitis.
It may give rise to a cyst or to an abscess.
Treatment is either endodontic therapy or removal of the tooth with curettage of the apical region.
On dental image it appears as a widened periodontal ligament space at the root apex.
This results from pulpal death or necrosis, or inflammation of the pulp.
Typically asymptomatic but has history of prolonged sensitivity to heat or cold.
The lamina dura is not visible between the root apex and the apical lesion.

27. Periapical Cyst
Iannucci & Howerton (p. 432) (Fig )
Periapical cyst is a lesion that develops over a long period.
It results from cystic degeneration of the periapical granuloma.
It is the most common of all tooth-related cysts.
It is typically asymptomatic.
Treatment is either endodontic therapy or extraction with curettage of the apical region.
Also known as a radicular cyst.
Results from pulpal death or necrosis.
Comprise 50% to 70% of all cysts in the oral region.
Appears as a round or ovoid radiolucency.

28. Periapical Abscess
Iannucci & Howerton (pp ) (Figs , 35-19)
This is a localized collection of pus in the periapical region of a tooth.
Acute
Painful, nonvital; sensitive to pressure, percussion, and heat
May not appear on dental images
Chronic
Usually asymptomatic; pus drains through bone or the periodontal ligament space
Appears as a round or ovoid apical radiolucency
Results from pulpal death.
Pain with acute abcess may be intense, throbbing, and constant.

29. Periapical Radiopacities
The following are a few of the common periapical radiopacities that may be seen on dental images:
These may be diagnosed based on their appearance, clinical information, and patient history
Condensing osteitis
Sclerotic bone
Hypercementosis

30. Condensing Osteitis Condensing osteitis is a well-defined radiopacity.
Iannucci & Howerton (p. 433) (Fig )
Condensing osteitis is a well-defined radiopacity.
It is seen below the apex of a tooth with a history of long-standing pulpitis.
May vary in shape and size; does not appear to be attached to the tooth root.
It is the most common periapical radiopacity observed in adults; most commonly in the mandibular third mola.
Also known as chronic focal sclerosing osteomyelitis.
The opacity represents a proliferation of periapical bone that is a result of a low-grade inflammation or mild irritation.
No treatment is necessary.

31. Sclerotic Bone
Iannucci & Howerton (pp ) (Fig )
Sclerotic bone is well-defined radiopacity seen below the apices of vital, noncarious teeth.
It is of unknown cause.
It is not attached to the tooth.
It varies in size and shape.
Margins may be smooth or irregular and diffuse.
It is asymptomatic.
Also known as osteosclerosis or idiopathic periapical osteosclerosis.
Usually discovered during a routine radiograph.

32. Hypercementosis
Iannucci & Howerton (pp ) (Fig )
Hypercementosis is the excess deposition of cementum on root surfaces.
May result from supereruption, inflammation, or trauma.
Most often affects the apical area, which appears enlarged and bulbous.
Affected teeth are vital and do not require treatment.
Root areas affected are separated from periapical bone by normal-appearing periodontal ligament space and lamina dura.