Radiology for stomatologists Lecture Jakub Stulík, prof. Karel Benda, Petr Nádeníček FN Brno_modra_obdelnik IMAGING MODALITIES in stomatology •Plain X–ray image •Contrast studies •Computed tomography •Ultrasoud •Magnetic Resonance 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) Plain X ray imaging •1) Imaging of skull • • •2) Dental radiographs • –A) Intraoral imaging – –B) Extraoral imaging 1) Skull skiagrams –Picture of the cranium –Projection of paranasal sinuses –Orbits –Skull base –Panoramatic: Upper and Lower jaw –Os temporale –Temporo-Mandibular Joint – • • Nose and forehead touch the cassette • X-ray pass through the protuber. occipitalis perpendicularly to cassete • Cranium – dorso-ventral and lateral projection • 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 Paranasal sinuses – Water´s projection •orbito-meatal line 07 •Orbito-meatal Line Orbits – dorso-ventral projection 09 09 • • Orbits – lateral projection •Skeleton Points •Soft Tissue Points •14 sella Skull base – axial projection 04 •http://rtg.misto.cz/_MAIL_/hlava/04.jpg 04 Skull base – axial projection 11 Os temporale – Stenver´s – semisagital pr. • 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- we can see calcifications • • • •Correct position of temporo mandible joint (TMJ) • • 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 •Interlude I. •Young man was stitching his trousers in the morning •Then he went to the pub in the evening. •After 4 beers he went home, sit on bed and feel sharp pain in his balls •Man mending his pants 2) Dental radiographs a) 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 RADIATION PROTECTION •Use of proper exposure and processing techniques •Patients should be shielded with lead aprons and thyroid shields. •These shields should have at least 0.5 mm of lead equivalent. •Film badges • IMAGE RECEPTORS •RADIOGRAPHIC FILM •DIGITAL RECEPTORS •indirect digital imaging Convenctional and digital technique •Digital: –CCD (charged coupled device) as a senzor • Films for intraoral exposure •dental films • • •plastic covering •Lead filtr on the back •paper covering on both sides of the film •film SIZES •Various sizes available, although only three are usually used routinely: •For periapical & bitewings • 31 X 41 mm • 22 X 35 mm •For occlusal • 57 X 76 mm Film processing: •Automatic processing machine •dirts •drop of water •neil •too fast taking film out of the cover Conventional film processing - artifacts • •correct temperature •cold chemicals •film is grainy • •fingerprint •contact with other film •too high temperature during developing Conventional film processing - artefacts • Digital technique amount of radiation incident on the detector at any spot is coded by gray shade – with 256 different gray shades Digital technique - advantages •filmless performance •frendly inspecting and storage of pictures •repeated exposure without medium changing •Interlude II. •Young man came to hospital with abdomen pain •Man with a bottle in his ass INTRA ORAL RADIOGRAPHS •Bitewing •Peri apical •Occlusal BITEWING •So called because patient closes the teeth together biting on a wing of card projecting from the tube side of the film •Demonstrates occlusal surfaces,inter proximal surfaces of enamel,enamel-dentine junction & the bone levels surrounding the tooth •Used for pre-molars,molars •indications: dental caries, assessment of fillings & crown,periodontology • PERIAPICAL •Shows usually 2-4 teeth,individual teeth & tissues around apices • • INDICATIONS •Detection of apical infection •Assessment of periodontal status •After trauma to teeth & associated alveolar bone •Assessment of root morphology before extraction •During endodontics •Detailed evaluation of apical cyst & other lesion within the bone •Evaluation of implants postoperatively • • • • OCCLUSAL •Utilize the largest intra oral film (6 X 8cm) •Various projections •Maxillary occlusal projections •-Upper standard •-Upper oblique standard •Mandibular occlusal projections •-lower 90 degree occlusal •-lower 45 degree occlusal •-lower oblique occlusal Indications • • •Interlude III. •Young man came to hospital with bleeding from noce after fencing with rapiers •Man with rapier in his nose 2b) Extraoral imaging •OPG - Orthopantomography •Single image of facial structures that includes maxillary •and mandibular arches •and their supporting •structures. •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 •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 Indications •Evaluation of trauma •Third molars •Large lesions •Tooth development •Developmental anomalies •Intolerant to intraoral procedures Advantages… •Broad anatomic coverage •Low patient radiation dose •Convenience of examination •Used in patients unable to open mouth Disadvantages •Does not show fine anatomic details •Magnification •Distortion •Overlapped image of teeth •Expensive • • • pan1 •Ext. Auditory meatus •Mandibular condyle •Articular eminence •Coronoid process •Zygomatic bone •Ptregomaxillary Fissure •Inf. orbital rim •Floor of Maxillary sinus •Ant. wall of Maxillary sinus •Hard palate •Nasal fossa •Inf. Orbital canal and foramen •Zyg. process of Maxilla •Panoramic Innominate line (Infra temporal surface of Zyg. bone •Lat. ptreg. plate •Man. fossa •Inf. border of Mandible •C- Spine •Mental foramen •Hyoid bone •Inf. Alveolar canal •Ext. oblique ridge •All this diagnostic information is missed in intraoral X-rays •Hard Tissue • • • pan3 •Inf. nasal concha (turbinate) •Inf. nasal meatus •Dorsal surface of the tongue •Post. Wall of the pharynx •Soft palate •Lower lip •Upper lip • • •Middle meatus •Ghost image of opposite Man. •Soft tissue (edentulous) •All this diagnostic information is missed in intraoral X-rays •Interlude IV. •Young man came to hospital with headache after falling from stairs. •Man with screw in his skull Other imaging modalities: • •Computed tomography (CT) • a)Classic CT b)Dental Cone Beam CT •CT images are acquired while the x-ray tube i rotating 360dg. around the patient •The x-ray beam is collimated in axial orientation and divergent to encompass the patient‘s width in the other orientation. •The intensity of attenuated x-rays emerging from the patient is measured with an array of minute detectors Classic CT Multislice CT •Several rows of detectors each above another •MS- detector array segmented in z axis, as a mosaic. •–Allows for simultaneous acquisition of multiple images in scan plane with ONE rotation. 07 08 Classic CT indication –Examination of facial soft tissue –parotid gland disease –diagnosing and staging tumors –diagnosis and assess the extent of osteomyelitis (inflammation of the jaw bone) –temporomandibular joint disorders –impacted teeth –complex traumatic injuries of facial skelet • •Complex fractures of facial skelet •Absces •The extensive osteolysis of the temporal bone •Postprocessing - reconstructions •Multiplanar rec. - MPR •Volume rendering technique - VRT •Shadow surface display - SSD 03-000_003_1 03-000_003_5 03-000_002_70 1 03-000_004_03 •/7 •72 How CBCT Works •Similar to current CT technology •Uses cone shaped x-ray beam •2-D flat panel detector •Gives volumetric data Theory •Dental Cone Beam CT • •/7 •73 Advantages in Dental Imaging •Lower dose than helical CT •Compact design •Superior images to Panoramic •Low cost •Low heat load • •Dose: •Panoramic: 6-20 µSv •CBCT: 20-70 µSv •Conventional CT: 314 µSv •/7 •74 CBCT •The i-Cat CBCT •Cephalometric CBCT image •Cephalometric Panoramic image •/7 •75 Shortcomings •Worse resolution in low contrast tissues •Long scan times = motion artifacts •Slightly Inferior quality to conventional CT •Periodontal ligament spaces easily recognizable in the dental CT but not satisfactory in the CBCT •CBCT •/7 •76 Applications of CBCT •Great for pre-planning for implant surgery •Virtual Surgery •Conventional CT diagnosis at 1/5 the dose •Tumor detection •Airway visualization • 3D-transparent •/7 •77 Conclusions •CBCT offers less dose than conventional CT •CBCT offers superior images and diagnosis to panoramic •More practical than a conventional CT airway_Page_1_Image_0003 Other imaging modalities: • • •Contrast studies •SIALOGRAPHY SIALOGRAPHY 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