Radiology for stomatologists Lecture Department of Radiology, University Hospital Brno 2013 c1196 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 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) •biconcaval disc, •correct position protect mandible joint (TMJ) •Intracapsul. dissease = diskopathy •Diskopathy = –disc dislocation üWith/ without reposition üadhese • • Temporomandibular joint - TMJ • x-ray beam passes 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 MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ MRI - TMJ Zavř 2 Otevř 2 Zavř 2 Otevř Ventral position with reposition Ventral position without reposition sono 1 zavř Ultrasound - 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 X-ray - attributes •Electromagnetic radiation of short wavelength produced when high-speed electrons strike a solid target (on anoda) •Ability to pass through tissues where are partially absorbed Radio-opacity (light) Radiolucency (dark) Films for intraoral exposure •dental films - conventional • • plastic covering Lead (Plumbum) filtr on the back paper covering on both sides of the film film Convenctional and digital technique •Digital: –CCD (charged coupled device) as a sensor •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 - artefacts dirts drop of water developer neil Electrostatic energy - 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) • • 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. Bite-wing-x-ray 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 üdiagnostics, 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 DSC_0379v • •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 holded 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 mandible joints on the picture 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) 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 – differential diagnostics 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 parotitis epidemica (mumps) Glandula parotis calcification •Transverse CT scan of ductal and glandular calcifications • Large solitary sialolith (arrow) in the right submandibular duct •These glandular calcifications (arrows) could easily be mistaken for vessels on this contrast-enhanced CT scan Figure 13a. Retentio abundant teeth Processus styloideus pain long proc. styl. 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 mesial posttraumatic central granuloma 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 Chronic. apical periodontis • Periodontitis chronica • Cysts •Odontogenic •Non-odontogenic •inflammatory 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. 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 medial part 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 Radicular cyst •cystis radicularis (234) purulenta •after intraoral incision excretion of pus and blood. •as a consequence of acute exacerbation of chronic apical parodotitis female, 57 y Sinusitis maxillaris •Liquid surface Sinusitis maxillaris Sinusitis maxillaris - RTG •woman, 17 y •acute catarrhal etiology Roe_SinusitisMaxillaris_Uto Sinusitis maxillaris - CT Sinusitis maxillaris - MRI 258 T2 weighed coronal Ethmoid sinus, mastoid cells Ethmoid. sinusitis Pathologic contents ANd9GcTz8hJmYzqbIG2YV4T8rDxKjyrsw8nesOiaJODQSWrz7UBZ3A4R F5 T2 •Oral cavity abscess. •Contrast-enhanced axial CT images obtained with soft-tissue and bone window settings show a fluid collection with rimlike enhancement in the left submandibular space. •The bone window image better depicts the source of infection. Figure 1a Periapical abscess 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. Carcinoma •the most often carcinoma of oral mucosa. •intraepitelial mucosal carcinoma •infiltration of: –adjacent bones –lingual part of mandible •osteolysis •paresthesis •smokers, older age • Carcinoma - mandible Carcinoma - bone lysis Carcinoma - mandible ANd9GcQA_Y7VWRwfUsrjKVjE_ghf5jngU-N9Av6kKkW0zdlWHzFNbQhp Mucoepidermoid carconoma in posterior mandible Carcinoma - mandible ANd9GcTv_qjN4acQo902_zJ8k6Jc8A-wwxRIyJLa8tUc9e5o9JtYBsyLAA CT squamous carcinoma of mandible Carcinoma - mandible ANd9GcTlN1jZnXZk2PI08UJqeUFpu9BFdAPmtQ6CYO6tAeSSwRVr80Qs Squamous cell carcinoma 70 y old man ANd9GcTIadeP6a8XpDmpYw1Z_BvKr081Cbr9vdr0EfhaY1-thpbAz8YAwA ANd9GcQMu335ccFpkt2KqhgVUWIygk0Wz8zW4eGTzfC9CHIQ30VoyJhy 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 • Ewing sarcoma boy, 7 y difficulty clinics oedema of low jaw movement of teeth periostal reaction ANd9GcRjcvcFCr3wYitaBH7dIDqbfRotVCXomtL8p3ST6gQseVscUL7g-A Ewing sarcoma Ewing sarcoma. Axial T1-weighted MR image gold diagnostic standard MRI Ewing sarcoma Ewing sarcoma. Axial and coronal CT image ANd9GcQ3kYPGlI4kc_r1LfXQHATYntk4TghDYzp_idNTxROl9rBIEXt7 ANd9GcT9O5dn6ALzq-mWG2i-iKq1qO84X5AtDdA5ESPhqGzBE3TlYqHnFQ Osteosarcoma •2. and 3. decennium •mesenchymal tumor •histologic –osteoblasts –chondroblasts –fibroblasts • – – • RTG - osteoblastic + osteolytic – various image Osteosarcoma female, 29 y Osteosarcoma • male, 40 y Osteosarcoma ANd9GcTVcd-FDZ3X-BlrfGYJQZbAGiTDEEj3IiA0biKKqZMoLWfwBtfK1A Axial and coronal CT image ANd9GcTOkO6_k0RlCO-qP8UHTakcHC0wLYRCRylN5mCpp3AaxCaQikJodw Low grade osteosarcoma of the mandible × 4. Low grade osteosarcoma of the mandible × 4. Low grade osteosarcoma of the mandible × 4. Histology: Low grade osteosarcoma of the mandible. 4x. ANd9GcTf8Mrb7OBWrCD82qC4efYSijWRjruEFpj3XBFjizwatvDP2iJv Osteosarcoma 20 year-old woman with left high grade mandibular osteosarcoma. MRI axial and coronal FSE T1-weighted sequence after gadolinium injection showing a well defined juxtacortical mass (tumor bone formation) developed along the surface of the left mandible. This mass is hypointense with mild peripheral rim enhancement. The cortical of the mandible is interrupted and the medulla shows heterogenous enhancement indicating tumor invasion. Full-size image (33 K) Full-size image (33 K) Full-size image (33 K) CT-scan volume reformation, inferior view, showing an ossified expansive tumor of the left mandible. 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 •male, 69 y •prostate carcinoma •transparency Metastasis •bowel carcinoma •spotted, blurred Metastasis ANd9GcTP4B90YytJZh6SzgBW4g3yq8c_Nsx9wNQdOGcvQHOoUyk8h3dUtQ Metastatic hepatocellular carcinoma in a 61-year-old man. Contrast-enhanced CT scan demonstrates an expansile, osteolytic mass (arrows) within the right mandibular body. Metastasis Mandibular metastasis from colonic adenocarcinoma T1-weighted axial T2 FS axial A 63-year-old female with history of adenocarcinoma of the colon initially presented to her physician with a swollen left parotid gland. Presumptive diagnosis of saldenitis was made and the patient was treated with antibiotics. After no response to antibiotics, MRI was performed. Subsequently a fine needle aspiration of the left mandibular mass was performed demonstrating malignant cells derived from adenocarcinoma with mucinous features similar to prior pathology slides of patient's colonic adenocarcinoma. Metastasis Mandibular metastasis from colonic adenocarcinoma MRI - post-contrast T1 Osteonecrosis mandibulae F7 Osteonecrosis mandibulae - MRI • 51-year-old woman with breast cancer. • Oblique sagittal T1-weighted image shows focal lesion of osteonecrosis (arrow) affecting mandibular branch and involving mandibular canal. Odont. myxoma •age 10-50 years •female/male 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 female, 34 y structure - net dense, irregular septum Odont. myxoma boy, 13 y Odontoma •similar to the hamartomas •conglomerate of various tooth tissues –composite odontoma ücontains several developed teeth –complex odontoma ücontains basic tooth 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 •Does not relapse • Ameloblastic fibroma Ameloblastoma „honeycomb“ structure •is a rare, benign tumor of odontogenic epithelium •male/female 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 L 5A5I copy bullet 5A5J copy 5A5L copy 5A5K copy Pathological fracture and apical cyst Maxillar fractures Le Forte •fracture of the maxilla •high energy trauma –100 times the force of gravidity •patient ussualy have multisystem 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 lefort1pic lefort1ct R •horizontal fracture •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. •floating palate 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 lefort2ap Le Fort II 5A6G copy 5A6G copy lefort2ap Le Fort II lefortap3 lefortlat3 1-15 5A6I copy • Transverse fractures • Zygomatic arch • Nasofrontal and frontomaxillary sutures • Nasolacrimal groove and ethmoid bones • Known as craniofacial dissociation the zygomatic arch Le Fort III Le Fort III Orbital fractures Orbita - anatomy •The force vector goes through thin orbit base, where arise fracture near infraorbital canal •Soft tissue goes beyond orbital rim •Injury of maxillar sinus •Dislocation of orbital base •Polypoid density at the upper maxillar edge and herniation orbital structures into the maxillar sinus •Buccal parestesis 5A8B copy Blow-out fracture 5A8B copy „Blow-out“ of left orbit and infraorbital canal Coronal CT scans 5A8B copy Blow-out fracture 5A8A copy Proc. Frontozygomaticus fracture + „blow-out“ fracture of left orbit Coronal CT scans Blow-out fracture 5A8E copy Blow-out fracture 5A8D copy „Blow-out“ fract. Inferior part of right orbit with mucous enlargement 5A8D copy Blow-out fracture 5A8C copy 5A8C copy Blow-out fracture 5A8F copy „Blow-out“ fract. of right orbit “trap door” sign. 5A8F copy Blow-out fracture Teeth subluxation 5A2A copy 5A2A copy Alveolar fracture 5A3D copy 5A3D copy THE END Department of Radiology, University Hospital Brno 2013 c1196