Radiology for stomatologists Lecture prof. Karel Benda, Petr Nádeníček FN Brno_modra_obdelnik Projections and Anatomy Lendmark lines •Frankfurt´s horizontal, antropological basic plane, connects caudal part of obrit to external to auditory meatus. •Camper´s plane connects the external auditory meatus to caudal part of nose. • Lendmark lines •Occlusal plane should be horizontally (black line) oriented or slightly inclined down (at small children) Extraoral skiagrams •Panoramatic: –Picture of the cranium –Projection of the maxillar sinus –TMJ – Temporo-Mandibular Joint –Orthopantomograph (OPG) •Tomography (CT, MRI) •Film or detector is placed out of the patient mouth. •Image of larger surface of mandibula, maxilla, soft tissues and the cranium • Nose and forehead touch the cassette • X-ray pass through the protuber. occipitalis perpendicularly to cassete Cranium – dorso-ventral and lateral projection Cranium – dorso-ventral and lateral projection •Centre •Tilting,etc. 02 Cranium – dorso-ventral and lateral projection • Central beam goes through the acustic meatus • Perpendicular to the cassette scan0009 Cranium – lateral projection • 03 Cranium – lateral projection •splanchnocranium centre Cranium – lateral projection Skeleton Points Soft Tissue Points 14 sella Cranium – semiaxial projection Paranasal sinuses – Water´s projection •orbito-meatal line 07 Orbito-meatal Line Paranasal sinuses – dorso-ventral projection •http://rtg.misto.cz/_MAIL_/hlava/06.jpg 06 06 Orbits – dorso-ventral projection •http://rtg.misto.cz/_MAIL_/hlava/09.jpg 09 09 Cranium – axial projection 04 •http://rtg.misto.cz/_MAIL_/hlava/04.jpg 04 Cranium – axial projection 08 08 Paranasal sinuses – axial projection •http://rtg.misto.cz/_MAIL_/hlava/08.jpg Mandible – panoramic projection •http://rtg.misto.cz/_MAIL_/hlava/15.jpg 15 15 Upper jaw – panoramic projection 14 14 11 Os temporale – Stenver´s – semisagital pr. •http://rtg.misto.cz/_MAIL_/hlava/11.jpg 11 12 12 •http://rtg.misto.cz/_MAIL_/hlava/12.jpg Os temporale – Schüller´s – semilateral projection • legenda138 Os temporale – Schüller´s – semilateral projection Temporomandibular joint (TMJ) •Intracapsul. dissease = diskopathy •Biconcaval disc, fibrocartilag. struct., cranial/caudal compartment of TMJ •Correct position protect mandible joint (TMJ) •Diskopathy = –disc dislocation üwith üwithout reposition üadhese • • Temporomandibular joint - TMJ • x-ray beam pass vertical +25° to center of film • entering 6-7cm over meatus acusticus. scan0013 serial radiogram TMJ • condyl head • fossa glenoidalis • close mouth • open mouth MRI - TMJ Zavř 2 Otevř 2 Zavř 2 Otevř Ventral position with reposition Ventral position without reposition sono1 def Sono2 def sono 1 zavř Ventral position with reposition Ventral position without reposition Sono - TMJ Intraoral exposures •voltage of X-ray tube –50-90 kV •filtration of primary beam –1,5 mm Al - U<70 kV –2,5 mm Al - U > 70 kV •body tube –length of body tube = 10-30 cm • Intraoral X-ray device min X-ray - attributes •Electromagnetic radiation of short wavelength produced when high-speed electrons strike a solid target •Ability to pass through tissues where is partially absorbed Radio-opacity (light) Radiolucency (dark) Films for intraoral exposure •dental films • • plastic covering Lead filtr on the back paper covering on both sides of the film film Convenctional and digital technique •Digital: –CCD (charged coupled device) as a senzor •standard formats • clasic 31x41 mm child 22x35 mm special 27x54 mm special 57x76mm •The film covering is larger than film (over 1 mm) Films for intraoral exposures Conventional film processing developer fixer cold chemicals film is grainy correct temperature little developing liquids Conventional film processing - artifacts dirts drop of water developer neil too fast taking film out of the cover Conventional film processing - artifacts fingerprint contact with other film too high temperature during developing brake emulsion layer up Conventional film processing - artefacts Digital technique 256 gray shades histogram no transitive shades Digital technique - advantages •filmless performance •frendly inspecting and storage of pictures •repeated exposure without medium changing •lower dose? Basic types of radiogram Basic types of radiogram Bitewing Periapical (Univ. Manitoba, 2005) •Panoramic - OPG • • • • • • • • • •(Univ. Manitoba, 2005) • • Intra-oral plain radiography (conventional + digital) Radiographic film/detector is exposed whilst inside the patient’s mouth Image of a small area - a few teeth and adjacent supporting structures Bitewing BW3Diag1 •Shows crowns of upper and low jews simultaneously. •Indications: -examintation of the occlusal line -examination of: -tooth caries -tooth loss -monitoring pictures, e.g. cured teeth -assessment of periodontal status bw2 Usually of posterior teeth but can be anterior teeth. structure - assessing existing restorations (defects, contacts) - assessment of periodontal status. Usually of posterior teeth but can be anterior teeth. Periapical exposures •Indications: -apical infection detection -trauma – tooth and alveolus -root assessment -orthodoncia – diagnostics, plan, theraphy, follow up Image of 1-3 complete teeth and the surrounding periodontal ligament and alveolar bone. Indications: detection of apical infection/inflammation dental trauma (to the tooth and associated alveolar bone) assessment of root morphology before extractions endodontic diagnosis, planning, treatment and monitoring Ortopanthomography - OPG •one exposure demonstrates: •jaws •teeth •joints •aleveolar recesses of jaw cavities • • IMG_0547 • •comfort •low radiation dose •better than intraoral RTG STATUS (traditional series of teeth) • Ortopanthomography - OPG •X-ray tube goes around the head on the track of ideal teeth occlusion - parabola •There are 3 rotatory centra very next to the teeth occlusion • Ortopanthomography - principle –Wisdom teeth –TMJ –Maxilar sinus –Fractures and other skeleton pathology –Orthodontia – Ortopanthomography - assessment •leyer thickness üfrom 9 mm (frontal part) ütill 20 mm (in the area of TMJ) –thinner leyer = less artefacts, higher radiation dose – •defocus •zoom •possibility of mesuring Ortopanthomography - technique Zonograms •= panoramic RTG exposures of different leyer thickness •variable leyer thickness during exposition •combination of zoom in (detail) technique •to better exposure –reduction of cervical vertebra summation üreduction of rotating velocity of X-ray tube üincrease the exposition parameters in the point of (x-ray) passing Burn-out effect •incorrect tongue position •x-ray beam is not reduced •= „overexposition “ of structures •negative contrast of air suppresses: –maxillar tooth roots –structures of maxilla –boundary of nasal and maxillar cavities •it is NOT possible to ASSESS – • tongue as a filtr Burn-out effect overexposed picture tongue as a filtr The breathig •deep breath and hold breath •epipharynx is filled up with the air –incorrect exposure of lateral part of picture – • „Don´t move and breathe calmly during the examination.“ Movement artefacts • Asymetry of exposure Pictured layer piercing - tongue piercing - lip Ortopanthomography - mistakes •The head hang (down) •the roots of caudal incisors are deviated of the plane •out of focus http://www.dentalcare.cz/odbclan.asp?ctid=auth&arid=425 •Tilting the head back •the root of cranial incisors are deviated of the plane •out of focus • Ortopanthomography - mistakes http://www.dentalcare.cz/odbclan.asp?ctid=auth&arid=425 Ortopanthomography - mistakes •The head is too close to the film •The teeth in both jaws –are smaller –out of focus •The cervical vertebras could summate with mandible arms http://www.dentalcare.cz/odbclan.asp?ctid=auth&arid=425 Ortopanthomography - mistakes •The head is far from the film •maxillar and manbidular teeth are –out of fucus –larger •there are not on the picture mandible joints http://www.dentalcare.cz/odbclan.asp?ctid=auth&arid=425 Alien body - artefacts •Ear rign on the right. •Artefact in the area of the left tuber maxillae. • •Metal zips, buttons, glasses, carelessly attached protect collar •= disturbing artefacts Alien bodies - artefacts Extraoral exposures Occlusal exposure of upper and low jaw Teeth arch •Parabole –frontal part (curved part of parabole) –distal part (arms of parabole) Topography •buccal – towards cheek •lingual – towards tongue •labial – towards lip •palatial – towards palatum •distal •mesial –label the ventral located structures „ventral-medial“ scan0015 scan0014 Oclussal exposures •Pictures of maxillar arch, mandible, periodontal ligaments, tooth sockets (alveolus) and adjacent bone •Indications: -teeth development monitoring -redundant teeth -pathology which is not possible to show on intraoral exposures -contours of buccal and lingual parts of palate skeleton -no possibility to perform intraoral exposure -limitation of mouth opening -no cooperation (children) Image of either the maxilla or mandibular arch including teeth, periodontal ligaments, alveolar bone and some basal bone. Indications: presence/absence of developing teeth supernumerary teeth impacted teeth pathology not fully demonstrated in an intraoral view contour of buccal and lingual cortical plate (usually Mn) localisation technique (used with another film) when unable to take intra-oral radiographs - limited opening of mouth - uncooperative child. Extraoral lateral exposure of frontal upper frontal part •depicture of nasal bones •alien particles glass fragments spina nasalis anterior perpendicular to film Mandible – dorso-frontal projection leg130 Mandible – dorso-frontal projection Semiprofile exposures of upper and low jaw • Mandible – lateral projection leg133 Caudal wisdom tooth •The head is tilted on heathy side and back •The x-ray beam passes through the wisdom tooth towards cranio-ventral oriented film cassette which is on the reverse side Chin exposure •horizontal placed film •imaging toothless chin • Anatomy legenda-premoláry115 Premolars a molars • Anatomy Molars, premolars, area of the tuber legenda109 legenda109 Anatomy Molars, premolars, area of the tuber Literature •Pasler F.A., Visser H.: Stomatologická radiologie. Kapesní atlas. 2007. ISBN 978-80-247-1307-6. •http://rtg.misto.cz/_MAIL_/index.html • Pathology - dif.dg. Retentio dentes • Tartar tartar is composed of mineralized tooth plaque + generalized bone reduction as a consequence of parodont pathology •origins in area of outfall of main salivary glands •calcium phosphate –x-ray opacity parodontitis marg. profunda sublingual tartar Concrements calcified cervical lymf. nodes calcification of gl. parotis as a consequence of parotitits epidemica (mumps) •as a consequence of acute exacerbation of chronic apical parodotitis w, 57 y Sinusitis maxillaris Sinusitis maxillaris •w, 17 y •acute catarrhal etiology 36 37 Marginal periodontopathy oversupply of root filling injury to the desmodont and mesodont of tooth root etiology: via falsa = interradicullar bone loss bone reducion between 35,37 as a consequence of amalgam overhang caries 34,37,38 11 mezial posttraumatic central granuloma chronic. apical periodontis • periodontitis chronica • Marginal periodontopathy traumatic occlusion etiology: fixed bridgework massive bone reduction sclerotic reactive zone - apically (36,37) alveolar and mandible bone reduction old age Marginal periodontopathy Periapical abscess A periapical abscess is the result of a chronic, localized infection located at the tip, or apex, of the root of a tooth. Cysts – odontogenic 1.primordial c. 2.keratocyst 3.folikular c. 4.lateral parodontal c. 2 1 Cysts – odontogenic 1.primordial c. 2.keratocyst 3.follicular c. 4.lateral periodontal c. 1 A primordial cyst is a devolepmental odontogenic cyst. It is found in an area where a tooth should have formed but is missing. Primordial cysts most commonly arise in the area of mandibular third molars. Cysts – odontogenic 1.primordial c. 2.keratocyst 3.follicular c. 4.lateral periodontal c. 1 Keratocyst is a benign but locally aggressive developmental cystic neoplasm. It most often affects the posterior mandible. foto - istologický nález: ł łBenigní cysta vystlaná oploštělým nerohovatějícím dlaždicovým epitelem; ł łje přítomen mírný ložískový zánětlivý infiltrát a krystaly cholesterolu ł łve vazivu stěny. Hlenotvorný epitel není přítomen. ł łMůže se jednat o folikulární cystu s mírným sekundárním zánětem (diff. dg. ł łradikulární cysta). Závěr - odentogenní (folikulární) cysta. Cysts – odontogenic 1.primordial c. 2.keratocyst 3.follicular c. 4.lateral periodontal c. 1 A follicular cyst is a cyst of dental follicle The dental follicle is a sac containing the developing tooth and its odontogenic organ. Cysts – odontogenic 1.primordial c. 2.keratocyst 3.folikular c. 4.lateral parodontal c. 1 The lateral periodontal cyst is a cyst that arises from the rest cells of the dental lamina. It is more common in middle-aged adult males. Usually, there is no pain associated with it, and it usually appears as a unilocular radiolucency (dark area) on the side of a canine or premolar root. Microscopically, the lateral periodontal cyst appears the same as the gingival cyst of the adult. Cysts – non-odontogenic 1.nasopalatine c. 2.nasolabial c. 1 Cysts – non-odontogenic 1.nasopalatine c. 2.nasolabial c. Nasopalatine cyst occurs in the median of the palate. 1 Cysts – non-odontogenic 1.nasopalatine c. 2.nasolabial c. 1 Nasolabial cyst is located superficially in the soft tissues of the upper lip. Unlike most of the other developmental cysts, the nasolabial cyst is an example of an extraosseous cyst. Cysts - inflammatory 1.apical radicular 2.lateral radicular 3.residual lateral 4.parodontal (Craig´s) - wisdom tooth 1 2 Carcinoma •the most often carcinoma of oral mucosa. •intraepitelial mucosal carcinoma •infiltration of: –adjacent bones –lingual part of mandible •osteolysis •paresthesis •smokers, older age • Osteonecrosis mandibulae • Radicular cyst •cystis radicularis -234 purulenta •after intraoral incision excretion of pus and blood. Zánětlivý stav dolní čelisti. Marek Pavel \ 16.04.1955 \ M \ 550416/2422 Carcinoma Carcinoma Ewing sarcoma •children 10-20 y •high grade malignant •fast grow •soon metastatis •angle of mandible •painfull •X-ray: „slices of onion“ •Dif.dg. –osteosarcoma –endosteal hemangioma • gold diagnostic standard MRI Ewing sarcoma boy, 7 y difficulty clinics oedema of low jaw movement of teeth periost reaction Osteosarcoma •2. and 3. decennium •mesenchymal tumor •histologic –osteoblasts –chondroblasts –fibroblasts • – – • RTG - osteoblastic + osteolytic – various image Osteosarcoma w, 29 y Osteosarcoma • m, 40 y Metastasis •carcinomas of: –mamma –lung –gl. thyreoidea –prostate •blood spread •clinics: –pain in the bones –„reasonless“ teeth release –paresthesis of lower lip –pathological fracture •suspicion = scintigraphy Metastasis •m, 69 y •prostate carcinoma •transparency Metastasis •bowel carcinoma •spotted, blurred Odont. myxoma •age 10-50 y •w/m 1:1 •jaws (only) •most often in lower jaw - caput of mandible •growth –fast –endosteal –muscle infiltration (occasionally) •good bounded, irregular translucency •often relaps • Odont. myxoma w, 34 y structure - net dense, irregular septum Odont. myxoma boy, 13 y Odontoma •similar to the hamartomas •conglomerate of various teeth tissues –composite odontoma ücontains several developed teeth –complex odontoma ücontains basic teeth tissues in amorphous mass • complex composite Odontoma composite composite after 2,5 year incidental findings– susp. calc. odontogen. cyst Odontoma complex Fibroma •Fibromas (or fibroid tumors or fibroids) are benign tumors that are composed of fibrous or connective tissue. Faciomax_ameloblastic_fibroma_ct Faciomax_ameloblastic_fibroma_ct1_mri •The ameloblastic fibroma is an odontogenic tumor arising from the enamel organ or dental lamina •tumor with odontogennal epithelium and ectomesenchyma •benign •10-20 y, boys •in molar mandible region •dif.dg. –folicular cyst –ameloblastoma •don´t recidivate • Ameloblastic fibroma Ameloblastic fibroma • Ameloblastoma „honeycomb“ structure •is a rare, benign tumor of odontogenic epithelium •m/w 1:1 •in a region of caudal molars (80%) •long-term relaps = radical resection •variable histological image – many of variants •RTG –multilocular –multicystic –bubble transparency with septum around –compacta thin out •slow growth, painless •oedema, facial asymetry Ameloblastoma •dif.dg. –folicular cysts –keratocysts –ameloblastic fibroma –odontogennal myxoma –central eosinofil granuloma • Myeloma is a cancer of the white blood cells known as plasma cells. • Hypercalcemia (corrected calcium >2.75 mmol/L) • Renal insufficiency attributable to myeloma • Anemia (hemoglobin <10 g/dL) • Bone lesions (lytic lesions or osteoporosis with compression fractures) • Frequent severe infections (>2 a year) • Amyloidosis of other organs • Hyperviscosity syndrome Mandible fractures Mandible fractures 32-11 Fract. processus articul. mandibulae bilat. mandible angle - sutura 5A5C copy Body symphysis 5A5I copy L 5A5I copy bullet 5A5J copy 5A5L copy 5A5K copy 5A5K copy Pathological fracture apical cyst Maxillar fractures Le Forte •high energy trauma •Classification: Le-Forte I-III •all types Le Forte involve processus pterygoideus • Fractures of the maxilla are high energy injuries. An impact 100 times the force of gravity is required to break the midface. These patients often have significant multisystem trauma. Many require resuscitation and admission. The fractures of the maxilla are classified as LeFort Fractures. 235-A LeFort I •horizontal fracture •'floating palate •The fracture extends from the nasal septum travels horizontally above the teeth apices •crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates. lefort1pic lefort1ct R LeFort I: Horizontal fracture of the maxilla at the level of the nasal fossa. Allows motion of the maxilla while the nasal bridge remains stable. The fracture is below the infraorbital nerve, so there is no hypesthesia. LeFort II • üMaxilla üMedial portion of orbits ünasal bones ü 239-B 1-14 L 5A6D copy LeFort II: Pyramidal fracture which includes a fracture through: Maxilla Nasal bones Medial aspect of the orbits 5A6E copy CT 3-D reconstruction 5A6F copy LeFort II lefort2ap Fraktury maxily 5A6G copy 5A6G copy LeFort II lefort2ap Fraktury maxily lefortap3 lefortlat3 LeFort III 1-15 5A6I copy • fractures (transverse) • known as craniofacial dissociation • involve the zygomatic arch • start at the nasofrontal and frontomaxillary sutures • extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. Orbital fractures „Blow-out“ fraktura •Síla se přenáší přes tenké dno orbity, kde dochází k fraktuře v blízkosti infraorbitálního kanálu. •Měkké tkáně přesahují okraj orbity. •Afekce maxilárního sinu. •Dislokace dna orbity. •Polypoidní denzita při horním okraji maxil. sinu při herniaci obsahu orbity. •Parestezie tváře. 5A8B copy Trauma Orbita orbit 5A8C copy „Blow-out“ fract. Water’s projection. 5A8C copy 5A2A copy Subluxation. 5A2A copy 5A3D copy 5A3D copy Alveolar fract. Periodontics: •Alveolar bone height •Alveolar bone health •Generalised vs localised • alveolar bone loss •Peri-radicular infection Bad perio radiograph