Allan G. Farman (Ed.) Panoramic Radiology

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3 (Ed.) Panoramic Radiology

4 (Ed.) Panoramic Radiology Seminars on Maxillofacial Imaging and Interpretation With 178 Figures, Mostly in Colour 123

5 , BDS, PhD (odont), DSc (odont), MBA, Diplomate of the American Board of Oral and Maxillofacial Radiology, Diplomate Japanese Board of Oral and Maxillofacial Radiology Professor of Radiology and Imaging Science, Department of Surgical and Hospital Dentistry, Clinical Professor of Diagnostic Radiology, Adjunct Professor of Anatomical Sciences and Neurobiology, The University of Louisville, Louisville, Kentucky 40292, USA This book was prepared in collaboration with Panoramic Corporation, Fort Wayne, Indiana Library of Congress Control Number: ISBN Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, wether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broad-casting, reproduction on microfilm or any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in it current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. Springer-Verlag is a part of Springer Science+Business Media springer.com Springer-Verlag Berlin Heidelberg 2007 The use of general descriptive names, registed names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editors: Dr. Ute Heilmann / Annette Hinze, Heidelberg, Germany Desk Editor: Wilma McHugh, Heidelberg, Germany Cover design: Frido Steinen-Broo, estudio Calamar, Spain Typesetting and Production: LE-TeX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Printed on acid-free paper 21/3100/YL

6 For my ideal wife, and fellow Oral and Maxillofacial Radiologist, Taeko Takemori Farman

7 Preface During a Chicago Midwinter Dental meeting some years ago, I was asked by representatives from Panoramic Corporation to recommend a good general textbook on panoramic radiography. I was informed there is a great deal of interest within the dental profession in obtaining clinically relevant information on how to achieve the maximum diagnostic yield from the panoramic radiograph. On my personal library shelf, I had several texts on panoramic radiography published by such eminent sources as Manson-Hing, Langlais, and Chomenko; however, when I looked at the dates of publication inside the front covers of these books, I was disappointed to find that the latest revision was made much more than a decade ago. A thorough search of the World Wide Web, including Bestwebbuys.com showed that I was not mistaken in thinking that there was no available text based upon modern panoramic technology. No easy-to-access, up-to-date resource on panoramic radiography existed in the English language. It is for this reason that I agreed to edit a newsletter on panoramic radiography that would be distributed as a service to the dental profession. My agreement was contingent upon editorial independence, strict avoidance of commercial content, and a focus on the interpretation of panoramic radiographs in general rather than radiographs made using a machine from one particular vendor. Each issue was to contain several pages of content, mostly devoted to one topic in each case. Since its inception in 2000, twenty-two episodes of Panoramic Imaging News have been published and, while the Newsletter is to continue, it has been decided to update and expand the subject materials published to date and present these in one convenient volume. The editor/author-in-chief wishes to thank Panoramic Corporation for its collaboration over the past five years and for permission to reproduce prior topics from Panoramic Imaging News in this book format. Louisville, Kentucky October 2006

8 Contents 1 Getting the Most Out of Panoramic Radiographic Interpretation Quality Assurance Image Projection Geometry Interpreting a Normal Panoramic Radiograph Anatomical Comparisons Test Ghost Images: Objects Outside the Image Layer that are not Entirely Excluded from the Panoramic Radiograph Anatomic Ghosts Jewelry Ghosts Lead Apron Prostheses Test Digital Options for Panoramic Radiology 15 in association with William R. Jacobs Film Disadvantages Film Advantages Digital X-ray Imaging Disadvantages Digital X-ray Imaging Advantages If I Decide To Go Digital, How Do I Get Into It? What Systems Are Available? Film Scanners and Cameras Photostimulable Phosphor Plates Solid-state Detectors Radiation Dosage Costs Interoperability References Panoramic Radiology: Risk Within Reason 25 National Council on Radiation Protection and Measurement: Radiation Protection in Dentistry (NCRP Report No. 145) US Population Radiation Exposure Principles of Radiation Protection Risk within Reason Risk within Reason from Panoramic Radiology Patient Safety Occupational Safety Going Digital Panoramic Dosimetry Summary References Test Panoramic Radiology: Role in ADA/FDA Use Guidelines The New Dental Patient Patients Having No Signs or Symptoms of Maxillofacial Disease The Recall Dental Patient Outcomes Evidence Screening for Dental Fitness Screening General Dental Patients Screening for Periodontal Disease Screening for Periapical Disease Orthodontic Screening Some Final Considerations References Test Panoramic Radiologic Appraisal of Anomalies of the Dentition in association with Christoffel J. Nortjé and Robert E. Wood Anomalies in Tooth Number Hypodontia Hypodontia and Clefts Hypodontia and Down Syndrome Hypodontia and Ectodermal Dysplasias 45 Supernumerary Teeth Anomalies in Tooth Size Macrodontia Microdontia

9 Contents Anomalies in Root Formation Dilaceration Taurodontism Enamel Pearl Connation Concrescence Supernumerary Roots Anomalies of Tooth Crowns Talon Cusp Dens Invaginatus Dens Evaginatus Panoramic Radiology: An Important Adjunct in the Assessment of Dental Morphology Tooth Structure Anomalies Enamel Hypoplasia Amelogenesis Imperfecta Dentinogenesis Imperfecta Radicular Dentin Dysplasia Coronal Dentin Dysplasia Odontodysplasia Concluding Remarks References Test Tooth Eruption and Dental Impaction Premature Eruption Retarded Eruption Dental Impactions Impacted Third Molars Impacted Canines Other Impacted Regular Teeth Impacted Supernumerary Teeth Resorption of Impacted Teeth Pathoses and Impaction Ectopic Dental Eruption Concluding Remarks References Panoramic Radiographic Assessment in Orthodontics Anibal M. Silveira in association with Pros and Cons Root Parallelism Quality Control American Board of Orthodontics Panoramic Requirement Conclusions References Test Assessing Growth and Development with Panoramic Radiographs and Cephalometric Attachments Eruption Sequence and Timing Normal Variations in Eruption Timing Sex Skeletal Pattern Ethnicity Local Causes of Delayed Dental Eruption.. 96 Systemic Conditions Delaying Dental Eruption Low Birthweight Second-hand Smoke Syndromes Delayed Puberty Factors in Premature Dental Eruption Assessment of Biological Age Using Hand-Wrist Radiographs Assessment of Biological Age Using Lateral Cephalograms Biological Age and Orthodontic Intervention Age and Identity Concluding Remarks References Test Panoramic Radiographic Appearance of the Mandibular Canal in Health and in Disease in association with Christoffel J. Nortjé Pathological Conditions of the Mandible 109 Benign Lesions Within the Mandibular Canal Malignant Lesions Within the Mandibular Canal Benign Lesions Peripheral to the Mandibular Canal Malignant Lesions Peripheral to the Mandibular Canal Lesions Obscuring the Mandibular Canal 113 Concluding Remarks References Test Pathological Conditions affecting the Maxillary Sinus in association with Christoffel J. Nortjé Overview of alternative imaging modalities

10 Contents XI Maxillary sinus disease frequencies Inflammatory conditions Mucous retention (extravasation) phenomenom Adjacent dental pathoses Benign cysts and neoplasms Other benign radio-opacity Dysplastic conditions affecting the maxillary sinuses Detection of maxillary sinus malignant neoplasia Summary References Test Panoramic Radiology: Endodontic Considerations in association with Stephen J. Clark Periapical Pathoses Providing a Comprehensive Radiographic Overview Follow Up Evaluation Maxillary Sinus Disease Related to Endodontic Therapy Endo-antral syndrome Aspergillosis Conditions that May Simulate Dental Periapical Pathoses Conclusion References Test Panoramic Radiology of Pericoronal Pathoses in association with Christoffel J. Nortjé and Robert E. Wood Follicular Cysts Envelopmental Keratocystic Odontogenic Tumor Ameloblastoma Adenomatoid Odontogenic Tumor Ameloblastic Fibroma and Fibro-odontoma Odontogenic Myxoma Calcifying Odontogenic Cyst Calcifying Epithelial Odontogenic Tumor 148 Malignancies Associated with Envelopmental Radiolucencies Regional Odontodysplasia Cherubism Cyst Boundaries in Radiologic Differentiation Concluding Remarks References Test Panoramic Radiology in Maxillofacial Trauma in association with George M. Kushner Fractures of Teeth and Alveolar Bone Fractures of the Body and Angle of the Mandible Dental Impactions as Predisposing Factors to Mandibular Fracture Panoramic Radiographs in Third Molar Assessment for Relationship to the Inferior Dental Canal Panoramic Radiographs and Mandibular Fracture Assessment Roles of Computed Tomography and Panoramic Radiology in Mandibular Fracture Detection Pathological Jaw Fracture Foreign Body Detection Fractures of the Maxilla Concluding Remarks References Test Panoramic Radiographic Detection of Systemic Disease Arthur H. Friedlander and Keith M. Norman in collaboration with, Christoffel J. Nortjé, and Robert E. Wood Detection of Carotid Artery Disease and also by Inference, Coronary Artery Disease Osteoporosis Evidence Supporting Panoramic Radiographs to Screen for Osteoporosis Evidence Against Using Panoramic Radiographs to Screen for Osteoporosis Osteoporosis and Periodontal Disease 173 Diabetes Mellitus Hyperparathyroidism Specific Infections Tuberculosis Syphilis Metastatic Malignancies Concluding Remarks References Test

11 XII Contents 16 Panoramic Radiology: Oncologic Dentistry Considerations in association with Zafrulla Khan What is Oncologic Dentistry? Cancer Therapy Effects on Oral Tissues Oral Mucositis Xerostomia Periodontal Disease Osteonecrosis Childhood Therapy Dental Restorations Affecting Radiation Therapy Planning and Application Dental Outcomes References Test Cephalometric Attachments Are Not Only of Value for Orthodontic Assessment Lateral Skull Projection Posterior-Anterior (PA) Projection Occipitomental Projection (Waters Technique) Reverse Towne Projection Submentovertex Projection Lateral-Oblique Projection of the Jaws Test Selected Abstracts Dental Caries Assessment Periodontal Disease Assessment Endodontics Selection Criteria Safety and Risk Digital Imaging Dental Implants Prosthodontics Orthodontics Growth and Maturity Oncologic Dentistry Jaw Fractures Dental Impactions Dental Anomalies Jaw Pathoses Systemic Diseases Test Frequently Asked Questions About Panoramic Radiography Panoramic Radiology Corporation staff led by Steve T. Yaggy in association with Subject Index

12 List of Contributors Stephen J. Clark, DMD Diplomate, American Board of Endodontics, Associate Professor, Department of Periodontics, Endodontics, Dental Hygiene, Director, Graduate Program in Endodontics, The University of Louisville, Louisville Kentucky 40292, USA BDS, PhD (odont), DSc (odont), MBA Diplomate of the American Board of Oral and Maxillofacial Radiology, Diplomate Japanese Board of Oral and Maxillofacial Radiology Professor of Radiology and Imaging Science, Department of Surgical and Hospital Dentistry, Clinical Professor of Diagnostic Radiology, Adjunct Professor of Anatomical Sciences and Neurobiology, The University of Louisville, Louisville Kentucky 40292, USA Arthur H. Friedlander, DMD Diplomate, American Board of Oral and Maxillofacial Surgery, Associate Chief of Staff and Director of Graduate Medical Education, VA Greater Los Angeles Healthcare System, Professor of Oral and Maxillofacial Surgery at the UCLA School of Dentistry, The Center for the Health Sciences, Los Angeles CA , USA William R. Jacobs President, WRJ & Associates, Dental Marketing Consultants, Homer Glen, Illinois Zafrulla Khan, DDS, MS, FACP Professor of Prosthodontics, School of Dentistry Adjunct Professor, Medical and Radiation Oncology School of Medicine Director, Maxillofacial/Oncologic Dentistry James Graham Brown Cancer Center University of Louisville, Louisville Kentucky 40292, USA George M. Kushner, MD, DMD Diplomate, American Board of Oral and Maxillofacial Surgery, Director, Graduate Program in Oral and Maxillofacial Surgery, The University of Louisville, Louisville Kentucky 40292, USA Keith M. Norman, BA Research Associate, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA Christoffel J. Nortjé, BChD, PhD (odont), DSc (odont) Diplomate American Board of Oral and Maxillofacial Radiology, Professor of Oral and Maxillofacial Radiology, University of the Western Cape, Belleville 7535, Republic of South Africa Anibal Silveira, DDS Diplomate American Board of Orthodontics Associate Professor, Department of Orthodontics and Pediatric Dentistry, Associate Director, Graduate Orthodontic Program, The University of Louisville, Louisville Kentucky 40292, USA

13 XIV List of Contributors Robert E. Wood, DDS, Dip Oral Radiol, MSc, PhD, FRCD (C) Oral and Maxillofacial Radiologist, Associate Professor, University Health Network/ Princess Margaret Hospital, Toronto, ON Canada Stephen T. Yaggy President, Panoramic Corporation Fort Wayne, Indiana, 46818, USA

14 1 Getting the Most Out of Panoramic Radiographic Interpretation Chapter 1 Learning Objectives After reading this chapter, the following knowledge should be gained: Appreciation of the formation of the panoramic image The ability to identify normal hard tissue and soft tissue anatomic structures depicted in the dental panoramic radiograph Quality Assurance As with any other radiographic method, optimum interpretable diagnostic images can only be achieved with careful quality assurance in patient positioning, in selecting appropriate exposure parameters and during processing. While panoramic radiography is easy to perform well if all the manufacturer s instructions are followed, it is equally easy to perform badly. Most errors are due to incorrect patient positioning, leading to excessive and sometimes disproportionate distortion. A correctly positioned patient s panoramic radiograph generally shows symmetry of the size of the mandibular rami and condyles, and the dental segments are in focus with a gentle downward convexity of the maxillary arch. Provided the patient bites correctly on the bite-block, the anterior structures are portrayed in the midline and the apices of the mandibular incisor teeth should be in full focus. Provided that the tongue is kept up in the roof of the mouth during exposure, the roots of the maxillary teeth are clearly demonstrated. It is less expensive in time and materials and in radiation to the patient to perfect your panoramic technique, than to make unnecessary repeat exposures. And the diagnostic yield from an excellent panoramic radiograph is far superior to one made under less rigorous quality control. To gain the maximum amount of diagnostic information from a dental panoramic radiograph (pantomograph), it is necessary to understand that panoramic radiographs are flattened out schemes of a curved image layer. Think of the plan view of the head (Fig. 1.1). The panoramic radiograph provides a plan of one side, then the midline, then the other side of the face and jaws. Imagine the panoramic detector (e.g., X-ray film) wrapped around the outside of the face. The actual panoramic film seems large in comparison with a 3M human phantom (Fig. 1.2). This is because the actual image from most panoramic systems is enlarged by about 20%. Figures 1.3 and 1.4 show a printed panoramic image reduced to life size superimposed on the phantom. These graphically explain the association between the panoramic radiograph and the represented structures. In reality the image is formed section by section behind the secondary slit. Figure 1.5 illustrates this process by putting the same printed panoramic image in place of the film cassette. The relative movement of the X-ray source and the camera during exposure creates the effect of wrapping the film about the patient s face (Fig. 1.6). This analogy to film wrapped around the face is equally applicable to the distribution of anatomic Image Projection Geometry Fig. 1.1 A panoramic radiograph simultaneously presents views from both sides of the patients face as well as providing a frontal perspective

15 Fig. 1.3 The lateral and more posterior structures are projected to each side of the panoramic radiograph Fig. 1.2 You can best understand the relative position of structures shown in a panoramic radiograph if you imagine the image layer to be bent around the patient s face Fig. 1.4 The anterior structures are shown in the midline of the standard panoramic projection Fig. 1.5 The panoramic image is formed sequentially from information passing through the machine s secondary slit collimator. The film or photostimulable phosphor detector moves past the secondary slit at the appropriate rate necessary to minimize mechanical distortion. For solid-state systems the movement is virtual rather than actual