It’s time for… Intraoral Radiographic

Steven R. Singer, DDS 212.305.5674 [email protected]

“Alas, poor Yorick!”

Radiographic Contrast Radiographic Contrast

The difference in densities between adjacent areas of the image Influenced by:

! Subject contrast

! Film contrast

! Beam energy and intensity

! Fog and scatter radiation

Radiographic Contrast Radiographic Contrast

By adjusting kVp, contrast can be By adjusting kVp, contrast can be varied varied ! High contrast films can enhance ! Low contrast films can enhance detection of lesions where subject contrast detection of subtle findings. between the lesion and healthy tissue is low ! Examples include: ! Examples include: " Calculus " Caries " Soft tissue outlines " Apical lucencies " Small changes in crestal

1 Radiographic Density Radiographic Density

The overall degree of darkening of the Exposure

radiographic image. Three factors ! Determines the # of photons that are which determine radiographic density absorbed by the emulsion are: ! Four exposure factors

! Exposure " kVp " ma ! Subject thickness " Impulses (time) ! Object density " Source to film distance

Radiographic Density Radiographic Density

Subject thickness Object Density. The denser the object and higher the atomic #, the better the absorption of photons.

Radiographic Density Subject Contrast

In decreasing order of density: Influenced by:

! Metallic restorations Thickness

! Enamel Density ! Dentin Atomic # ! Bone ! Fat/fluid Relatively differences in Subject ! Air Contrast of oral structures allow the image to be seen

2 Subject Contrast Definitions

Radiodensity: The degree to which the subject attenuates the x-ray beam Radiopacity: An area of the image where the beam has been relatively highly attenuated Radiolucency: An area of the image where the beam has been relatively minimally attenuated

Radiolucencies Radiopacities

Marrow spaces Fossae Bone Teeth Foramina Meati Condyles Enamel Canals (N.B. the Sinuses Eminences Dentin Processes walls of the Sutures Cementum Tuberosities are opaque) Dental pulp Fissures Walls of canals Tubercles Ridges Trabeculae

The Teeth The Teeth

Enamel 90% mineralized Enamel Dentin 75% mineralized Dentin Cementum 50% mineralized Pulp Pulp Soft tissue

3 The Teeth The Teeth

Cervical burnout Concavities

Supporting Structures of the The Teeth Teeth Trabecular bone Fluting of root surfaces

Bone in the Anterior Bone in the Posterior Maxilla

Trabeculae are thin and numerous Similar pattern to anterior maxilla Small marrow spaces Slightly larger marrow spaces

4 Bone in the Anterior Bone in the Posterior Mandible

Trabeculae are somewhat thicker than in the maxilla Horizontal Plates Plates are in a horizontal pattern Larger marrow spaces than anterior mandible

Supporting Structures of the Supporting Structures of the Teeth Teeth

Crestal bone

Supporting Structures of the Supporting Structures of the Teeth Teeth

Lamina dura The between Periodontal the tooth and the ligament space bone is a gomphosis. The periodontal ligament allows for movement around a center of rotation.

5 Supporting Structures of the Landmarks Teeth

Lamina dura and PDL

facial view palatal view Landmarks in the Maxilla f b c f Intermaxillary suture e Nasal Fossa a d e Nose Lateral fossa

a = nasal septum e = b = inferior concha f = median palatal c = nasal fossa suture d =

Landmarks in the Maxilla Pterodactyl gr. pteron, wing

Incisive foramen Median palatine suture Pterygoid plates

6 Landmarks in the Maxilla Coronoid Process

Anterior nasal spine From the Greek word for “Crow’s Beak” Pterygoid plates Coronoid process of the mandible Nasolabial fold

Maxillary Incisor Landmarks in the Maxilla a Latyeral pterygoid b plate a = nasal septum c b = inferior concha Pterygo-maxillary d c = nasal fossa fissure e d = anterior nasal spine Zygomatico- e = incisive foramen f = intermaxillary suture temporal suture g = soft tissue of nose Zygomatic process f of the maxilla

g

facial view Landmarks in the Maxilla

Intermaxillary suture Soft tissue of the nose Incisive foramen

Nasal fossa

7 Landmarks in the Maxilla Landmarks in the Maxilla

Soft tissue of the The red arrows nose point to the soft tissue of the nose. The green arrows identify the lip line.

Landmarks in the Maxilla Landmarks in the Maxilla

Foramina of Nasopalatine canal von Ebner

Landmarks in the Maxilla Landmarks in the Maxilla

Incisive foramen Incisive foramen

8 Maxillary Canine Landmarks in the Maxilla a

b a = floor of nasal fossa c b = c = lateral fossa d = soft tissue of the nose

d Anterior nasal spine

facial view Landmarks in the Maxilla

Lateral fossa

Lateral fossa. The radiolucency results from a depression above and posterior to the lateral incisor. To help rule out pathoses, look for an intact lamina dura surrounding the adjacent teeth.

Maxillary Premolar Landmarks in the Maxilla a b c Nasal Fossa a = zygomatic process of maxilla b = sinus septum c = sinus recess d = floor of the maxillary sinus e = maxillary sinus

d e

9 Maxillary Premolar facial view

a b c b b c d c d a = zygomatic a a process of maxilla b = sinus septum c = sinus recess d = floor of the maxillary sinus e = maxillary sinus a = zygomatic process b = sinus recess d e c = sinus septum d = floor of the maxillary sinus

Maxillary Molar Landmarks in the Maxilla

Nasolabial fold a = e f b = coronoid process c = hamular process d d = pterygoid plates c

e = zygoma b a f = maxillary sinus

Landmarks in the Maxilla Landmarks in the Maxilla

Zygomatic Process and Maxillary Sinus Zygomatic Process and Maxillary Sinus

10 Pneumatization. From the Latin “filled with air” Expansion of sinus wall into surrounding bone, usually in areas where teeth have been lost prematurely. Increases with age. Mucositis Halo effect

Landmarks in the Maxilla Landmarks in the Maxilla

Maxillary tuberosity Hamular process Coronoid process of the mandible

Hamular process Tuberosity

Hamular process Hamular process Tuberosity

Coronoid Process

facial view Landmarks in the Mandible

Mental ridges Mental fossa Maxillary Tuberosity. The rounded elevation located at the posterior aspect of both sides of the maxilla.

11 Mandibular Incisor The Thinker Auguste Rodin, 1881

a. b. genial tubercles c. mental ridge d. mental fossa

d

a bc

Landmarks in the Mandible Landmarks in the Mandible

Mental foramen Mylohyoid (Internal Inferior alveolar oblique) ridge (Mandibular) Submandibular canal gland fossa Inferior border of the mandible

Landmarks in the Mandible Landmarks in the Mandible

External oblique Genial tubercles ridge Mental Ridge Inferior border of the mandible

12 lingual view lingual view facial view Lingual view Facial view Landmarks in the Mandible

d c b a a b a

a = lingual foramen c = mental ridge a = Lingual foramen b = Mental ridge b = genial tubercles d = mental fossa

facial view Mandibular Canine

a = mental ridge c b = genial tubercles/ lingual foramen c = mental foramen

Mental fossa. This represents a depression on the b labial aspect of the mandible overlying the roots of the a incisors. The resulting radiolucency may be mistaken for pathosis.

facial view lingual view lingual view

dbb2 da dc db1 Lingual foramen/ genial tubercles.

a = mental ridge b1 = genial tubercles c = mental foramen b2 = lingual foramen

13 facial view Landmarks in the Mandible

Inferior border of the mandible

The red arrows identify the and the blue arrow points to the mental foramen.

Mandibular Premolar Landmarks in the Mandible

Submandibular gland fossa

a = mylohyoid ridge b = mandibular canal c = submandibular gland fossa d = mental foramen

Mandibular Molar Landmarks in the Mandible

Mental Foramen and Inferior Alveolar Canal

a = external oblique ridge b = mylohyoid ridge c = mandibular canal d = submandibular gland fossa

14 facial view Landmarks in the Mandible a bb External oblique ridge Internal oblique ridge (a.k.a mylohyoid ridge)

c d a = external oblique ridge b = mylohyoid ridge c = mandibular canal d = submandibular gland fossa

lingual view

b a

d c Mylohyoid (internal oblique) ridge. This radiopaque ridge is the attachment for the mylohyoid a = external oblique ridge muscle. The ridge runs downward and forward from the b = mylohyoid ridge third molar region to the area of the premolars. c = mandibular canal (inferior border) d = submandibular gland fossa

facial view

External oblique ridge. A continuation of the anterior border of the ramus, passing downward and forward on The mandibular canal (red arrows identify inferior border of the buccal side of the mandible. It appears as a distinct canal) usually runs very close to the roots of the molars, radiopaque line which usually ends anteriorly in the area especially the third molar. of the first molar. Serves as an attachment of the buccinator muscle. (The red arrows point to the mylohyoid ridge).

15 Restorations Restorations

Gold Metallic Restorations Amalgam Bases and liners Titanium Stainless Steel Gutta Percha Porcelain Composites Cements and Liners

Restorations Restorations

Implant restorations Stainless steel post Root-end amalgam

Restorations Restorations

Porcelain Composites: Radiolucent and Radiopaque Gold Gutta percha Stainless steel

16 Restorations Acknowledgement

Posterior composites Thanks to OSU College of Dentistry for the use of some of the slides, diagrams, and radiographs.

Questions Thank you!

Thanks!

17