p*- icliology for storriatologis'ig 5.10.2003 Petr Nádeníček Department of Radiology, University Hospital Brno and Medical Faculty, Masaryk University, Brno,Czech 2008/9 Radiograms • Extraoral skiagrams (X-ray pictures) -Cranium - Focus on separate regions of the cranium - Orthopantomogram (OPG) • Intraoral skiagrams Projections; and Anaiorny sndrriark lines; Frankfurt s horizontal, antropological basic plane, connects caudal part of obrit to external auditory meatus. plane connects the external auditory meatus to caudal part of nose. sndrriark lines; Occlusal plane should be horizontally (black line) oriented or slightly inclined down (at small children). Exíraoral skiagrams • Panoramic: - Picture of the cranium - Projection of the maxillar sinus -TMJ - Temporo-Mandibular Joint - Orthopantomogram (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. Cranium - dorso-vsrítrahaM • Nose and forehead touch the cassette. • X-ray pass through the protuber. occipitalis perpendicularly to cassete. Cranium - c projection • Centre • Tilting,etc. ■ventral and laiera Cranium - dorao-ventral eine Sagittal suture Frontal crest Granular pits Lambdoid suture Inner table Lambdoid suture Frontal sinus Crista galii Orbita (roof) Sphenoid plane, Hypophyseal fossa -(floor) Medial wall of orbit —- Bony ethmoid cells -Foramen rotundum ——' Maxillary sinus -~" Nasal septum Styloid process ' Atlanto-oecipital articulation ^ Inferior nasal concha Mandibular angle Innominate line Supraorbital margir ^ Lesser wing _ Frontozygomatic suture Superior orbital fissure ~_ Pneumatization of temporal bone ~ Petrous ridge Zygomatic arch Innominate line Mastoid cells Mastoid process Nuchal plane Odontoid process of axis Transverse process of atlas Mandibular angle Maxilla (lateral contour) Lateral atlantoaxial articulation Arch of atlas Mental protuberance projection • Central beam goes through the acustic meatus • Perpendicular to the cassette Cranium - lateral projection Anterior clino Groove for spheno parietal sinus Coronal suture Diploe of frontal bone External layer of frontal bone Internal layer of frontal bone Greater wing of sphenoid bone Orbital part of frontal bone Crista galli Sphenoid plane Hypophyseal fossa / Posterior clinoid process of dorsum seilae ' / Groove for the middle meningeal artery /(dorsal main branch) Canals for diploic veins Frontal sinus Cribriform plate of ethmoid bone Frontozygomatic suture -- ^ Ethmoidal cells ^._ Nasal bone -_ __ Orbit {contour) —j Frontal process of zygomatic bone Tubercle of sella turcica -~ Sphenoid sinus (wall) Maxillary sinus (roof) — Zygomatic process of maxilla (ipsilateral) I Zygomatic process of maxilla (contralateral) Anterior nasal spine — -. Coronoid process of — " mandible Hard palate " ^f/t Vomer -^ Posterior nasal spine" Nasal part of pharynx Soft palate Oral cavity Mental protuberance Sigmoid sinus (anterior contour) Occipital spur (variant) — Foramen magnum -^ ~" Mastoid process ■v ""■-■-. Condylar process of mandible ^ ^--. (contralateral) N -> x Posterior tubercle of atlas i N Spinous praoess of axis Anterior arch of alias Mandibular angle (ipsilateral) Hyoid bone / Condy Mandibular angle (contralateral) lar process of mandible (ipsilateral) 9 Cranium-latere v^Diancnnocr t * projection csmn Skeleton Points 1 Nasion 2 Spina nasalijanterior Spina nasalis posterior 4 Bod A 5 BodB 6 Pogonion 7 Menton 8 Gonion 9 Basion 10 Artioilare 11 Condylion 12 Porion 13 Orbitale Soft Tissue Points 14 sella I Kožní na s ton II Špička nosu 111 Subnasaíe IV Subspinale V Labralesuperíus VI Sto m ion VII La brale inferius VIII Submentale IX Kožní pogonion X Kožní gnathion 32 Cranium - sjernieixieil projector Sutura sagittalis 18 Sinus frontalis se septy 19 Crista galli a falx cerebri 20 Lamina cribrosa ossis ethmoidals 21 Os nasale 22 Orbita 23 Linea innominata (alias majores] 24 Ala minor ossis sphenoidal Fossa cranii media (ohraničení) 25 10 Canalis opticus 26 11 Fissura orbitalis superior 21 Canalis infraorbitalis 28 Foramen rotund urn 29 La byrinthus ethmoidals 30 5eptum nasi osseum 31 Ccnchae nasales 32 Sinus maxillaris 33 12 13 14 15 16 17 Os zygomaticum Processus frontalis ossis zygomatici Sutura zygomaticofrontalis Arcus zygomaticus Crista zygomaticoalveolaris Processus condylars mandibulae Processus muscularis (coronoideus) mandibulae Celullae mastoideae Pars petrosa ossis temporalis Spina nasalis anterior Spina nasalis posterior Spina sphenoidalis Pars basilaris ossis occipitalis Dorsum linguae Massa lateralis atlantis Dens axis (epistrophei) Paranasal si i - Water's; projection Anterior ethmoidal cells Nasal bone Foramen rotundum Nasal septum — Posterior ethmoidal -"' cells Coronoid process of mandible Ethmoidal cells Contour of orbit / X , Floor of orbit / / ^ Innominate line ^--Zygomatic bon Infraorbital foramen ' Maxillary sinus Maxillary sinus, inferotateral wall Superior dental arch Vomer Sphenoidal sinuses (right and left) Maxillary sinus (alveolar concavity) Superior dental arch li Lower lip Inferior dental arch .450 Orbito-meatal line Paranasal sinuses - dorso-vsnira t * projection Sphenoid plane Supraorbital extension ot ethmoid air cells Lesser wing ^ Supraorbital extension of ethmoid air cells Ethmoidal — ~ cells Foramen rotu n bum Hypophyseal fossa (floor) „ Innominate line — Zygomatic bone Petrous ridge Nasal septum' Inferior nasal concha Floor of orbit Maxillary sinus 1 / X I ' Alveolar process of maxilla Nuchal plane mrp;//ngJrnisb,cz/jVJAJWriJava/üöjpg Orbito-meatal line Orbits* - dorso-ventral projection Middle meningeal artery sulcus Lesser wing of sphenoid bone -Innominate line Superior orbital fissure Zygomatic bone Nasal septum " Hypophyseal fossa (floor)' Anterior ethmoidal cells -Zygomatic arch " Foramen rotundum Petrous ridge Inferior nasal concha Maxillary sinus http:yfflg.rniai:o.cz/_JVJAJL_/hlaya/09.jpg C rain i u m - Pharynx '' Mastoid cells Anterior arch of atlas Cervical spine (contour) Odontoid process of axis hi{p://rig.rnJ2io.cz/jVJAJL_/nJcivsj/u4 jpg Paranasal sinuses - axial projection Inferior dental arch Nasal septum Frontal sinus Maxillary sinus Maxillary sinus (lateral wall) Infraorbital margin Orbita (wall) Middle cranial fossa (anterior margin), greater wing Body of mandible Coronoid process of mandible Oval foramen .- Spinous foramen htip://ri:g.rr]iE5to.Gz/jVJAJL_/J']lciVci/ü3.jprj Mandible - panoramic projection Canine tooth Premotar teeth Metallic fillings Molar teeth Pulp cavity '^„Unerupted tooth - Mandibular canal apex of tooth Pu|p cana| of ,ootn H}ip://n JEB^^MM^JL /hlsjvsj/1 5,jpcj Upper jaw - panoramic projection Ob temporale - Sienver's) - sernisagital pr. Cochlea Anterior semicircular canal Mastoid antrum Internal occipital crest Mastoid cells' Mastoid process ; i Mandibular fossa • http://rtg.misto.ez/_MAIL_/hlava/11 .jpg Internal acoustic meatus Petrous ridge Orbito-meatal line Head of mandible Cte 'temporale - Schi t * oroiecrjon m er b — ej e rn i J en era http://rtg.misto.cz/_MAIL_/hlava/12.jpg Posterior petrous angle = Angulus Cite Hi Sigmoid sinus sulcus Petrous ridge Ear (folded back) Bony labyrinth Hypophyseal fossa Zygomatic process (anterior root) Articular tubercle Head of mandible Articular fossa Styloid process Mastoid process Orbito-meatal line Cte tempore) p — aysr-serriiaxial pr. http://rtg.misto.cz/_MAIL_/hlava/13.jpg temporomandibular joint - TIVIJ IM >:: * JU, jg. Is. (j ÍÍ*ÍÍÍt( .s; Central ray 25° serial radiogram TMJ X-ray beam pass vertical +25 degree to center of film. Entering 6-7cm over meatus acusticus. • condyl head • fossa glenoidalis • closed mouth • opened mouth fflaoicil exposure rriraoral X-ray device Voltage of X-ray tube - 50-90 kV Filtration of primary beam - 1,5mmAI-U<70kV - 2,5 mm Al - U > 70 kV Body tube - length of body tube = 10-30 cm n ŕ * i rums ror intraoral sxj dental films plastic covering lead filter on the back paper covering on both sides of the film ^OEiurs J I Films for intraoral exposures • standard formats clasic 31x41 mm special 27x54 mm special 57x76mm • The film covering is larger than film (over 1 mm) cxíraoral exposure ŕ ŕ cxiraorai lateral exposure onronia upper frontal pari spina nasalis anterior perpendicular to the film • depicture of nasal bones • alien particles glass fragments Occlusal exposure /0 i» ^, >#^ * r i or upper and low jaw orsjo-rronig! projection i * orsjo-rronceiJ projection 1 Crista frontalis 2 Squama ossis temporalis 3 Pars petrosa ossis temporalis 4 Eminentia arcuata 5 Processus mastoideus ossis temporalis 6 Sinus sphenoidalis v superpozici s částí sinus frontalis 7 Crista galii 8 Planum sphenoideum 9 Articulatioatlantooccipitalis 10 Processus transversum atlantis 11 Processus pterygoideus ossis sphenoidalis 12 Eminentia articularis 13 Arcus zygomaticus 14 Oszygomaticum 15 Margo inferior, orbita 16 Sinus maxillaris 17 Cavumnasi 18 Concha nasalis inferior 19 Septum nasi osseum 20 Dens axis (epistrophei 21 Articulatio atlantoaxial 22 Spina nasalis anterior 23 Processus condylaris mandibulae 24 Kondyl us, fades articularis 25 Angulus mandibulae 26 Processus muscularis (coronoideus mandibulae 27 Canalis mandibulae 28 Foramen mentale 29 Corpus vertebrae cervicaIts III Serriiprofils exposures of upper and low 1 Kondylus 2 Eminentiaarticularis 3 Arcus zygomaticus 4 Suturazygomaticoalveolaris 5 Processus pterygoideus ossis sphenoi-daiis 6 Oszygomaticum 7 Sinus maxillaris 8 Tuber maxillae 9 Processus muscularis (coronoideus) 10 Incisura semilunaris 11 Lingula 12 Canaiis mandibulae 13 Foramen mentale 14 Crista temporalis 15 Os hyoideum 16 Angulus mandibulae (blíže ohnisku) 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. c im exposure • Horizontal placed film • Imaging toothless chin Teeth arch Parabole -frontal part (curved part of parabole) -distal part (arms of parabole) HSTAJi LAIIAk WJCC*-L \ <-ray - "ři. H I 183 • 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) 25 Basic types; of radiograms Periapical Bitewings Panoramic ri i (Univ. Manitoba, 2005) niraon radiograpriy • Film/detector is exponated in patient's mouth • Small area showing, e.g. a (very) few teeth and part of periodotium - Bitewing 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 condition Periapical exposures; Indications: - apical infection detection - trauma - tooth and alveolus - root assessment - orthodoncia - diagnostics, plan follow up cxíraoral exposure OcluE)EJ8il exposures Pictures of maxillar arch, mandible, fferiodantäl ligaments, tooth sockets (alvefjus) ani adjacent bone Indications: - teeth development monitoring - redundant teeth - pathology which is not possiblélijshow on intraoral exposures - contours of buccal and lingual skeleton - no possibility to perform intraoral exposure - limitation of mouth opening - no cooperation (children) Oriopaníhornogrsiphy - OPG • One exposure demonstrates: -jaws - teeth -joints -aleveolar recesses of jaw cavities Oríopanihornography - OPG • Advantages: - comfort - low radiation dose - better than intraoral RTG STATUS (traditional series of teeth) 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. Qriopanthorriography - ggssjsrrisrrt -Wisdom teeth -TM J - Maxilar sinus - Fractures and other skeleton pathology - Orthodontia íninorriograpriy - leanruque Leyer thickness -thinner leyer = less artefacts, higher radiation dose Defocus Zoom Possibility of mesuring 17 Zonograrns • = 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 ^reduction of rotating velocity of X-ray tube ^increase the exposition parameters in the point of (x-ray) passing Thickness; of the layer • from 9 mm (frontal part) • till 20 mm (in the area of TMJ) m L * t * agnciarci exposure m norrnoposmjon • you could explain the course of the examination to the patient • remove metal (ear rings,..., orthodontal devices, piercing) • right posture, let shoulder down 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 cavitjes^^ • it is NOT possible to ASSESS ton§ueasamtr r> üurn-out e overexposed picture tongue as a filtr Hie breathing____________________ „Don't move and breathe calmly during the examination." deep breath and hold breath epipharynx is filled up with the air - incorrect exposure of lateral part of picture Pictured layer piercing - tongue piercing - lip Oríopanihornography - mistakes • The head hang (down) • The roots of caudal incisors are deviated of the plane • Out of focus Qrtopeiníhomocjreiphy - mistakes • Tilting the head back • The root of cranial incisors are deviated of the plane • Out of focus http: //www. dentalcare. cz/odbclan. asp?ctid=auth&arid=42 5 Oríopanihornography - 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=42 5 Qrtopeiníhomocjreiphy - mistakes • The head is far from the film • Maxillar and manbidular teeth are: - out of focus - larger • There are not on the picture mandible joints Pathology 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 I parodontitis marg. profunda sublingual tartar ConcremeniEJ calcification of gl. parotis as a consequence of parotitits epidemica * t * Sínusmis) ma as a consequ chronic aoical n: * t * DinuBiíiEJ maxi ans siciiie asiicirrhcil etiology »' !\ l\ irginal pairocloníopaichy bone reducion between 35,37 as a consequence of amalgam overhang caries 34,37,38 I 1 mesial posttraumatic central granuloma 36 37 oversupply of root filling injury to the desmodont and mozodont of tooth root etiology: via falsa = interradicullar bone loss 11 Marginal parodontopathy traumatic occlusion etiology: fixed bridgework (quadrant 3) massive bone reduction sclerotic reactive zone - apically (36,37) !\ l\ ' LI irginai pairoaonxopacny Carcinoma the most often carcionoma of oral mucosa intraepitehal mucosal carcinoma infiltration of: - adjacent bones - lingual part of mandi osteolysis parestesis smokers, older age Carcinoma BüJOUpJBO nwing sarcoma • children 10-20 year old • high grade malignant • fast g row • soon metastatis • angle of mandible • painfull • X-ray: „slices of onion" • Dif.dg. - osteosarcoma - endosteal hemangioma gold diagnostic standard MRI nwing BEircomai • boy, 7 year old • difficulty clinics • oedema of low jaw • movement of teeth • periost reaction jggoseircornei • 2. and 3. decennium • mezenchymal tumor • histologie - osteoblasts - chondroblasts - fibroblasts RTG - osteoblastic + osteolytic - various image Osteosarcoma Osteosarcoma i i >^Uk üL siasias carcinomas of: - mamma - lung - gl. thyreoidea - prostate blood spread clinics: - pain in the bones - „reasonless" teeth release - parestesis of lower lip - patological fracture suspicion = scintigraphy i t smmis prostate carcinoma transparency Metastasis • bowel carcinoma • spotted, blurred Qdori'L myxoma ■ age 10-50 y » 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 Qdori'L rriyxorn structure - net dense, irregular septum .1 Qdori'L myxoma Odontoma simillar to the hamartomas conglomerate of various teeth tissues - composite odontoma ^contains several devoloped teeth - complex odontoma ^contains basic teeth tissues in amorphous mass composite Odontoma complex Odontoma incidental findings-susp. calc. odontogen, cyst after 2.5 composite U composite Ameloblastic "fibroma • 10-20 y, boys • benign • tumor with odontogennal epithelium and ectomesenchyma • in molar mandible region • dif.dg. -folicular cyst -ameloblastoma • does not recidivate Ameloblastic fibroma I r ■Vrisloblasííorrig male/female 1:1 benign; long-term relaps = radical in a region of caudal molars (80% variable histological image - man RTG - multilocular - multicystic - bubble transparency with septum^around - compacta thin out slow growth, painless oedema, facial asymetry I r ■Vrisloblasííorrig • dif.dg. - folicular cysts - keratocysts - ameloblastic fibroma - odontogennal myxoma - central eosinofil granuloma + ' ^H í - ^H Periapical abscess /lyelorris Literature • Pasler F.A., Visser H.: Stomatologická radiologie. Kapesní atlas. 2007. ISBN 978-80-247-1307-6. • http://rtg.misto.cz/_MAIL_/index.html