RADIOLOGY IN CONSERVATIVE

DENTISTRY

Oskar Armata
Department of Conservative Dentistry
 REVIEW OF HISTORY

• Wilhelm Conrad Röntgen discovered x-rays

in 1895.

• 22.12.1895 - Roentgen carried out the first

x-ray picture of his wife’s hand. Exposition
time – 20 minutes!
 REVIEW OF HISTORY

• In 1895, German dentist Otto Walkhoff made

the 1st dental radiograph.
X-RAY DIAGNOSTIC IN CONSERVATIVE
DENTISTRY
• X-rays in dentistry serves as the most important
diagnostic tool.
• Radiographs in dentistry are divided into two groups:
1. Intraoral radiograph.
2. Extraoral radiograph.
X-RAY DIAGNOSTIC IN CONSERVATIVE
DENTISTRY
• Intraoral Radiography
1. Periapical radiography
2. Occlusal radiography
3. Bitewing radiography
• Extraoral Radiography
1. Panoramic Radiography (Pantomography)
2. Cone Beam Computed Tomography (CBCT)
X-RAY DIAGNOSTIC IN CONSERVATIVE
DENTISTRY
Intraoral X-rays are the most common type of X-ray.
It is used mainly for:
• Detection of caries.
• Check the health of the tooth root and bone
surrounding the tooth.
• Check the status of developing teeth.
• Monitor the general health of your teeth and jawbone.
ORAL RADIOLOGY VS DENTAL CARIES
• Radiology is useful for detecting dental caries
due to the demineralization of enamel and dentin in
caries process.
• The lesion in the radiograph is a radiolucent
(darker) zone.
X-RAY DIAGNOSTIC IN CONSERVATIVE
DENTISTRY
General guidelines on patient care:
❑ For intraoral radiography the patient should be positioned
comfortably in the dental chair, ideally with the occlusal
plane parallel to the floor.
❑ Spectacles, dentures or orthodontic appliances should be
removed.
❑ A protective lead thyroid collar should be placed.
❑ Intraoral film packets should be positioned carefully to avoid
trauma to the soft tissues.
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
• Periapical radiography describes intraoral techniques
designed to show individual teeth and the tissues
around the apices.
• Each film usually shows two to four teeth and provides
detailed information about the teeth and the
surrounding alveolar bone.
PERIAPICAL RADIOGRAPHY
The periapical view is taken of both anterior and posterior teeth.
The objective of this type of view is to capture the tip of the root on
the film. This is often helpful in determining the cause of pain in a
specific tooth, because it allows a dentist to visualize the tooth as
well as the surrounding bone.
PERIAPICAL RADIOGRAPHY
Radiographic techniques:
➢ The bisected angle technique.
➢ The paralleling technique
The bisecting-angle technique
 THE BISECTING-ANGLE TECHNIQUE
• The bisecting-angle technique is based on a simple
geometric theorem, Cieszynski’s rule of isometry, which
states that two triangles are equal when they share one
complete side and have two equal angles.
 THE BISECTING-ANGLE TECHNIQUE
• Receptor is positioned as close as possible to the lingual surface
of the teeth, resting in the palate or in the floor of the mouth. The
plane of the receptor and the long axis of the teeth form an angle,
with its apex at the point where the receptor is in contact with the
teeth. An imaginary line that bisects this angle, direct the central
ray of the beam at right angles to this bisector .
THE BISECTING-ANGLE TECHNIQUE
 THE BISECTING-ANGLE TECHNIQUE
Advantages:
• No film holder required.
• Decreased exposure time .
• Positioning of the film packet is reasonably comfortable
for the patient in all areas of the mouth.
• Positioning is relatively simple and quick.
• If all angulations are assessed correctly, the image of the
tooth will be the same length as the tooth itself and
should be adequate (but not ideal) for most diagnostic
purposes.
 THE BISECTING-ANGLE TECHNIQUE
Disadvantages:
• To reproduce the length of each root of a multi-rooted
tooth accurately, the central beam must be angled
differently for each root.
• Another limitation of this technique is that the alveolar
ridge often projects more coronally than its true position,
thus distorting the apparent height of the alveolar bone
around the teeth.
 THE BISECTING-ANGLE TECHNIQUE
Disadvantages:
• The many variables involved in the technique often result
in the image being badly distorted.
• Incorrect vertical angulation will result in foreshortening or
elongation of the image.
• The periodontal bone levels are poorly shown.
• The shadow of the zygomatic buttress frequently overlies
the roots of the upper molars.
• The horizontal and vertical angles have to be assessed
for every patient and considerable skill is required.
 THE BISECTING-ANGLE TECHNIQUE
Disadvantages:
• It is not possible to obtain reproducible views.
• Coning off or cone cutting occur.
• Incorrect horizontal angulation will result in overlapping of
the crowns and roots.
• The crowns of the teeth are often distorted, thus
preventing the detection of approximal caries.
• The buccal roots of the maxillary premolars and molars
are foreshortened.
Paralleling technique
 PARALLELING TECHNIQUE
• Principle: The central concept of the paralleling is that
“the x-ray receptor is supported parallel to the long axis of
the teeth and the central ray of the x-ray beam is directed
at right angles to the teeth and receptor
 PARALLELING TECHNIQUE
• Minimizes geometric distortion and presents the teeth and
supporting bone in their true anatomic relationships
 PARALLELING TECHNIQUE
• The film packet is placed in a holder and positioned in the
mouth parallel to the long axis of the tooth.
PARALLELING TECHNIQUE

• The X-ray tubehead is then aimed at right angle

(vertically and horizontally) to both the tooth and the
film packet.
PARALLELING TECHNIQUE
PARALLELING TECHNIQUE

Advantages:

❑ Geometrically accurate images are produced with little

magnification.
❑ The shadow of the zygomatic buttress appears above
the apices of the molar teeth.
PARALLELING TECHNIQUE

Advantages:

❑ The periodontal bone levels are well represented.

Periapical tissues shows minimal foreshortening or
elongation.
❑ Crown of the teeth shows approximation of the caries.
PARALLELING TECHNIQUE

Advantages:

❑ The horizontal and vertical angulations of the X-ray

tubehead are automatically determined by the
positioning devices if placed correctly.
❑ The X-ray beam is aimed accurately at the centre of
the film — all areas of the film are irradiated and there
is no coning off or cone cutting.
❑ Reproducible radiographs are possible at different
visits and with different operators.
PARALLELING TECHNIQUE

Disadvantages

• Positioning of the film packet can be very

uncomfortable for the patient, particularly for posterior
teeth, often causing gagging.
• Positioning the holders within the mouth can be
difficult for inexperienced operators.
• The anatomy of the mouth sometimes makes the
technique impossible, e.g. a shallow, flat palate.
PARALLELING TECHNIQUE

Disadvantages

• The apices of the teeth can sometimes appear very

near the edge of the film.
• Positioning the holders in the lower third molar regions
can be very difficult.
PARALLELING TECHNIQUE

Disadvantages

• The technique cannot be performed satisfactorily

using a short focal spot to skin distance (i.e. a short
spacer cone) because of the resultant magnification.
• The holders need to be autoclavable or disposable.
INDICATIONS FOR PERIAPICAL
RADIOGRAPHY
• Detection of apical infection/inflammation
• Assessment of the periodontal status
• After trauma to the teeth and associated alveolar bone
• Assessment of the presence and position of unerupted teeth
• Assessment of root morphology before extractions
• During endodontic treatment
• Preoperative assessment and postoperative appraisal of apical
surgery
• Evaluation of apical cysts and other lesions within the alveolar
bone
• Evaluation of implants postoperatively.
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY

2001
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
PERIAPICAL RADIOGRAPHY
DENTAL ABNORMALITIES
PERIAPICAL RADIOGRAPHY
DENTAL ABNORMALITIES
PERIAPICAL RADIOGRAPHY
DENTAL ABNORMALITIES
PERIAPICAL RADIOGRAPHY
PERIODONTITIS
PERIAPICAL RADIOGRAPHY
PERIODONTITIS
PERIAPICAL RADIOGRAPHY
PERIODONTITIS
PERIAPICAL RADIOGRAPHY
DENTAL CARIES
PERIAPICAL RADIOGRAPHY
ROOT CARIES
PERIAPICAL RADIOGRAPHY
ROOT CARIES

Not clearly, out of focus demarcated, cupped brightening

BITEWING RADIOGRAPHY
BITEWING RADIOGRAPHY
Bitewing (also called interproximal) radiographs include
the crowns of the maxillary and mandibular teeth and the
alveolar crest on the same receptor. .
BITEWING RADIOGRAPHY
The bitewing radiography is the most useful radiographic
examination for detecting caries.
BITEWING RADIOGRAPHY
• Clinical studies shows that radiographic
examination can revel carious lesions both in
occlusal and proximal surfaces.
INDICATIONS FOR THE BITEWING
RADIOGRAPHS:
• Early diagnosis of caries
• Checking the marginal closure of restorations and crowns
in the proximal area
• Documentation of calculus accumulation in the proximal
spaces of posterior teeth
• Condition of the alveolar ridge in the posterior region
INDICATIONS FOR THE BITEWING
RADIOGRAPHS:
• Secondary caries below restorations.
• Overhanging restorations.
• Evaluating the periodontal condition(alveolar bone
crest) detecting calculus deposits.
BITEWING RADIOGRAPHY
CARIES DETECTION
• Proximal surface
the shape of early radiolucent lesion in the enamel is classically
a TRAINGLE with its broad base at the tooth surface spreading
along the enamel rods, but other appearance are common, such
as a NOTCH, a DOT, a BAND, or a thin LINE.
 BITEWING RADIOGRAPHY
• Proximal caries susceptible zone. This region extends
from the contact point down to the height of the free
gingival margin. It increases with recession of the alveolar
bone and gingival tissues.
 B
A

C
D
BITEWING RADIOGRAPHY

Occlusal surfaces
• Occlusal lesions commonly start in the sides of fissure wall
rather than at the base and then tend to penetrate nearly
perpendicularly toward DEJ.
• Early lesion appear clinically as a chalky white, yellow, brown. or
black discolorations of the occlusal fissures.
BITEWING RADIOGRAPHY
• Buccal and lingual surface
Difficult to differentiate between buccal and lingual caries on
radiograph and its outline is not well defined.
• Occlusal lesions are more extensive than lingual or buccal
caries.
BITEWING RADIOGRAPHY
SECONDARY CARIES
• A carious lesion (radiolucency) developing at the
margin of an existing restoration may be termed
secondary or recurrent caries.
 PROXIMAL CARIES NEED TO BE
DIFFERENTIATED FROM :

• Radiolucent shadows appearing at the neck of teeth, most obvious on

mesial and distal aspects.
• Enamel abnormalities, eg. underdevelopment of the enamel.
• Tooth wear
PROXIMAL CARIES NEED TO BE
DIFFERENTIATED FROM :
Cervical burn-out
OCCLUSAL RADIOGRAPHY
OCCLUSAL RADIOGRAPHY
• An occlusal radiograph displays a relatively large
segment of a dental arch.
OCCLUSAL RADIOGRAPHY
Indications:
• the anatomy of the palate or the bottom of the mouth.
• when patients are unable to open the mouth.
OCCLUSAL RADIOGRAPHY
Indications:
• to localize foreign bodies in the jaws and stones in the
ducts.
• to demonstrate and evaluate the integrity of the outlines
of the maxillary sinus
PANORAMIC RADIOGRAPHY
PANORAMIC RADIOGRAPHY
• It visualize the entire upper (maxilla) and lower
(mandible) jaw including the teeth, maxillary sinuses,
and nasal cavity.
PANORAMIC RADIOGRAPHY
Indications

1: Evaluation of trauma
2: Third molars
3 :Extinsive disease such as large lesions
PANORAMIC RADIOGRAPHY
Indications

4: Tooth development (mixed dentition)

5: Retained teeth or root tips (in edentulous patients)
6: Developmental anomalies
7: Panoramic radiographs are also useful for patient who
don’t tolerate intraoral procedures well.
PANORAMIC RADIOGRAPHY
Advantages
1. Broad coverage of the facial bones and teeth
2. Low patient radiation dose .
3. Simple & fast technique
4. The fact that it can be used in patient .unable to open
their mouths
PANORAMIC RADIOGRAPHY
Disadvantages
1. The image doesn’t display the fine anatomic detail
available on intra oral Periapical Radiograph
2. Uneven magnification and geometric distortion.
3. The presence of overlapping structures such as the
cervical spine can hide the incisor region
PANORAMIC RADIOGRAPHY
Technique and positioning
1. patients should be asked to remove any earrings .
Jewelry hair pins spectacles dentures or orthodontic
appliances
2. the procedure and equipment movements should be
explained to reassure patients
PANORAMIC RADIOGRAPHY
Technique and positioning
3. patients should be placed accurately within the
machines using the various head-positioning devices
and light-beam marker positioning guides
4. patients should be instructed to place their tongue into
the roof of the mouth so that it is in contact with hard
palate and not to move throughout the exposure cycle
( approximately 18 second )
PANORAMIC RADIOGRAPHY
PANORAMIC RADIOGRAPHY
PANORAMIC RADIOGRAPHY
PANORAMIC RADIOGRAPHY
DIGITAL PANORAMIC RADIOGRAPHY
CBCT
 CBCT
• Anatomically accurate 3-D
information
• Identify possibilities and
limitations of treatment
• Better communication with
patients
 CBCT

Large field
of view
 CBCT

Medium
field of
view
CBCT

Small field of view

 CBCT - Voxel
Imaging Area
50
mm

▪ Voxel (VOlume piXEL) is

the smallest building block 38
.

mm

of a 3-D image

.076m
.076 m
mm

.076m Cubic Voxel

m
CBCT
Resolution:
a) 75 μm
Slices:
b) 90 μm 1. Sagittal
c) 125 μm 2. Axial
3. Frontal
d) 200 μm 4. Transsectional
5. Contiguous
CBCT

Transverse
or Axial

Coronal Sagittal
CBCT

Transverse
or Axial

Contiguous Transsectional
ALARA PRINCIPLE

AS LOW AS REASONABLY ACHIEVABLE

• Radiograph selection criteria

• Properly trained and credentialed personnel
• Optimal technique factors
• X-ray detector
CBCT
CBCT should be usde only when the need for imaging
cannot be answered adequately by lower dose
radiography.
 CBCT

Low KMT, et al,

JOE 2008
CBCT
CBCT
DIAGNOSIS OF MISSED CANALS
MB2
DIAGNOSIS OF COMPLICATIONS
Strip peroration is now observed
RESORPTION

?
?
CONCLUSIONS
CBCT is perfectly positioned for endodontics
• Focused FOV
• Minimal radiation
• Highest resolution
• Real-time analysis
LITERATURE
1. Radiologia stomatologiczna, Stuart C. White; Lublin, 2003
2. Nowe możliwości obrazowania kanałów korzeniowych z użyciem stomatologicznej tomografii wolumetrycznej, Ingrid
Różyło-Kalinowska i T. Katarzyna Różyło; Magazyn Stomatologiczny nr 4/2010
3. Mora MA, Mol A, Tyndall DA, Rivera EM. In vitro assessment of local computed tomography for the detection of
longitudinal tooth fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:825-9
4. Hassan B, Metska. ME, Ozok. AR, van der Stelt P, Wesselink PR. Detection of vertical root fractures in endodontically
treated teeth by a cone beam computed tomography scan. J Endod 2009;35:719-22.
5. Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR. Comparison of five cone beam computed tomography
systems for the detection of vertical root fractures. J Endod 2010; 36:126-9.
6. Wenzel A, Haiter-Neto F, Frydenberg M, Kirkevang LL. Variable- resolution cone-beam computerized tomography with
enhancement filtration compared with intraoral photostimulable phosphor radiography in detection of transverse root
fractures in an in vitro model. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:939-45
7. Bernardes RA, de Moraes IG, Húngaro Duarte MA, Azevedo BC, de Azevedo JR, Bramante CM. Use of cone-beam volumetric
tomography in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:270-7.
8. Özer SY. Özer SY. Detection of vertical root fractures by using cone beam computed tomography with variable voxel sizes in
an in vitro model. J Endod 2011;37:75-9.
9. Mora MA, Mol A, Tyndall DA, et al. Effect of the number of basis images on the detection of longitudinal tooth fractures
using local computed tomography. Dentomaxillofac Radiol 2007;36:382–6
10. Różyło-Kalinowska I., Różyło T. Katarzyna, Tomografia komputerowa wiązki stożkowej w diagnostyce pionowego złamania
korzeni zębów – badanie in vitro., Czas. Stomatolog., 2010, 63, 3, 191-198.
11. Krzyżostaniak J., Surdacka A., Rozwój i zastosowanie tomografii wolumetrycznej CBCT w diagnostyce stomatologicznej –
przegląd piśmiennictwa, Dental Forum, 2010, 2, XXXVIII.
12. Youssefzadeh S, Gahleitner A, Dorffner R, et al. Dental vertical root fractures: value of CT in detection. Radiology
1999;210:545–9.
13. Olek A., Analiza porównawcza morfologii i cech fizyko-chemicznych szkliwa i zębiny stałych zębów ludzkich, bydlęcych i
świńskich. Badania in vitro. Praca doktorska, Łódź, 2012
14. Zou X, Liu D, Yue L, Wu M. The ability of cone-beam computerized tomography to detect vertical root fractures in
endodontically treated and nonendodontically treated teeth: a report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2011;111:797–801.
THANK YOU FOR YOUR ATTENTION!