the role of ct examination in diagnosis and treatment of advanced period on tit is

8/3/2019 The Role of CT Examination in Diagnosis and Treatment of Advanced Period on Tit Is

1/9

SSiillvviiaa TTeessllaarruu,, SSiillvviiaa MMaarr uu

30 | S o c i e t a t e a d e P a r o d o n t o l o g i e d i n R o m

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AAVVAANNSSAATTEE

SilviaTeslaru1,

1

PhD., Department of Periodontology, Facul

ABSTRACT

Today, in periodontology, the diagnosis is based

not only upon clinical examination, but also upon

laboratory examinations (microbiological,

radiographic, possibly genetic). Radiographic

evaluation of bone is an indispensable classic

diagnosis method that completes the data obtained

rom deep periodontal measurements, allowing

estimation of the amount of peripheral bone and

possibly interradiculare, but that can not portray the

exact topography and morphology of apical lesions.

Keywords: radiographic evaluation, periodontal

dissesses

REZUMAT

paraclinice (microbiologic, radiografic, eventual

un element indispensabil diagnosticului, completand

ntual interradicular,

dar nu poate vizualiza exact topografia si morfologia

leziunilor infraosoase.

Cuvinte cheie:

parodontala

INTRODUCTION

In current periodontology, the diagnosis is

based not only upon clinical examination, but also

upon laboratory examinations (microbiological,

radiographic, possibly genetical methods).

Radiographic evaluation of bone is anindispensable classic diagnosis method that

completes the data obtained from deep

periodontal measurements and allows estimation

of the amount of peripheral and possibly

interradiculare bone, but can not portray the exact

topography and morphology of apical lesions.

As Meyer states, the items that are followed in

a radiographic examination are: the dental

anatomy, the degree and the shape of bone loss

(interdental and interradiculare septum), lamina

durra, the cortical vestibular oral bone (the gapbetween them), the trabecular bone, the desmo-

INTRODUCERE

examenelor paraclinice (microbiologic,

radiografic, eventual genetic).

element indispensabil diagnosticului,

exact topografia si morfologia leziunilor

infraosoase.

interradicular), lamina dura, corticalele osoase


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TTHHEE RROOLLEE OOFF CCTT EEXXAAMMIINNAATTIIOONN IINN DDIIAAGGNNOOSSIISS AANNDD TTRREEAATTMMEENNTT OOFF AADDVVAANNCCEEDD PPEERRIIOODDOONNTTIITTIISS

R o m a n i n J o u r n a l o f P e r i o d o n t o l o g y , v o l . 1 , i s s u e 1 , 2 0 1 0 | 31

dontal space, and the root proximities [1, 2, 3].

The classic radiographic examination, the

ortopantomographics, the retro-tooth alveolar

and bite-wing radiographs are limited as a

means of investigation; they do not reveal the

early alterations of the periodontium and it is atwo-dimensional representation of a three-

dimensional object.

Radiographic analysis does not allow

determination of the following aspects:

morphology of bone defects (number of bone

vertical walls), the exact position of the

vestibular and oral cortical, the presence and the

severity of periodontal pockets, septum

interradiculare illness at the superior molars by

overlapping roots, view intraosseous pockets.

Some of these deficiencies are clinicallydetectable, while others require further

investigations, such as: CT examination

(computer tomography or classical beam-con -

CBCT). In the absence of such information,

diagnostic data are insufficient for establishing

an appropriate treatment strategy for each case.

MATERIAL AND METHOD

CASE STUDY

To illustrate the benefits of computer

tomography exploration and of the data analysis

using the Dental CT program we propose the

study of a 27 year old patient, diagnosed with

aggressive periodontitis in advanced stage,

located in the teeth 16, 11,21, 36 and lower

frontal group.

RESULTS

Reason for the patient referral to the office

was the aesthetics issue of pathological migration

located at the superior central incisors, with the

development of pathological trema by vestibular

and distal-vestibular-rotation (fig. 1).

The appearance of longer teeth and the

emergence of the interdental free spaces in the

lower front group were embarrassing for the

patient.

Family history shows no significant issues.

The presence of an increased sensitivity in the

upper respiratory tract should be noted in

from tonsillitis and pharyngitis. The patient is

non-smoking, with a good hygiene.

Clinical examination shows deep periodontal

Examenul radiografic clasic, pe

ortopantomografie, radiografii

retrodent -wing, este limitat ca

bi- -dimensional.

orfologia defectelor

afectarea septului interradicular la molarii

vizualizarea pungilor infraosoase serpiginoase.

suplimentare, cum ar fi prin examen CT

(computer tomograf clasic sau cu fascicul-con -

e de

unei strategii terapeutice adecvate fiec rui caz.

STUDIU DE CAZ

rii datelor prin

programul Den

inferior.

REZULTATE

fost problema estetica generate de migrarea

-vestibulo-

Deranjant pentru pacienta era si aspectul de

dinte lung, cu aparitia spatiilor interdentare

libere la nivelul grupului frontal inferior.

Antecedentele heredocolaterale nu

antecedentele personale ar fi de remarcat


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pockets, located in teeth 15-16, 11, 21, 36 and

moderately active periodontal recession in the

lower front group (fig. 2, 3).

-16, 11, 21,

36, moderat active, recesiuni parodontale la

nivelul grupului frontal inferior (fig 2, 3).

Fig.1.Patient P.A., 28 years, the initial clinical aspects. Fig. 4. Ortopantomographics, patient P.A

Ortopantomografie, pacienta P.A.

Fig 2, 3. Patient P.A. Periodontal survey in teeth 11 and 22 reveal deep periodontal pockets of 8 and 7mm

Pacienta P.A. Sondajul

7mm.

Ortopantomographics is an essential comple-

mentary test that focuses on overall damage of

periodontal support; it shows marked loss of

alveolar bone in these teeth, the vertical and

alveolar loss predominantly affecting

interradiculare bone in the 36 region (fig. 4).

Measurements performed on ortopantomo-

graphics are not exact, only indicative

considering changes of teeth image, due to the

characteristics of this technique. However, the

level of alveolar bone crest can be measured byapplying a correction factor that is characteristic

for each device. Also the horizontal size

measurement is not real due to the

bidimensional character of the image.

All panoramic radiographs also involves

image distortions 30% in horizontal direction and

at least 50% in vertical direction. Consequently,

panoramic radiography, although a first choice

examination in periodontology, represents an

insufficient method for assessing the periodontal

status, because it does not reveal thickness ofalveolar the ridge, the vestibular and oral

Ortopantomografia este un examen paraclinic

ize predominant verticale si

afectarea osului interradicular la nivelul lui 36

(fig. 4).

M sur torile efectuate pe ortopantomografie

nu sunt exacte, ci doar orientative urmare a

deform ririi imaginii, caracteristice acestei

tehnici. Cu toate acestea, se poate realizam

fiec rui aparat. De asemenea, m surarea

dimensiunilor pe orizontal nu este real datorit

red rii bidimensionale a imaginii. Toate

radiografiile panoramice implic

imaginii de pan

,

radiografia panoramic

prim o

metod insuficient de apreciere a statusuluiparodontal, deoarece nu ofer


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cortical bone architectural defects and the

measurement of the alveolar bone loss is

generating significant errors. The major

disadvantage of this type of examination in fact

is that the image is very unclear due to the

movement flux (video and tube) and to theoverlap of cervical spine.

Supplementatal investigation with

radiographs is required at 18-17 due to the

presence and proximity of root, at 11-21, at 32-

42 due to changes of image by superimposing of

the image of the cervical vertebrae (fig. 5, 6) at

36 - 37 in order to explain the cortically

vestibular and lingual gap and architectural

intraosseous defects.

Information on horizontal alveolar loss in the

lower front group is superior byortopantomographics, as well as at 11-21, where

it is observed a sharp alveolar loss without

complete removal trabecular structure at this

level, which allows presuming the existence of

intraosseous defects with one or two vertical

bone walls. One can notice the lack of contour

with high density at the interdental bone; this is

a sign of periodontal illness activity in the

patient.

In so far the examination points out clearly at

some important issues: the vestibular and oralcortical, the number of vertical bone walls at

periodontal pockets infraosseoss, the size of

these defects in vestibular -oral, topography of

interradiculare septum damage, especially in

maxilla molars (e.g. 16); these are the necessary

data for establishing a correct and complete

diagnosis and also in order to choose the best

treatment methods (regenerative or surgical).

grosimea crestei alveolare, a corticalelor

infraosoase, iar m surarea dimensiunilor

alveolizelor genereaz erori semnificative.

Inconvenientul major al acestui tip de examinare

rezid imaginea nu este foarte clardin cauza fluu-

datorit suprapunerii coloanei cervicale.

Se impune suplimentarea cu radiografii retro-

dentoalveolare la 18-17 da

-21,

32-42 datorita imaginii fluu prin suprapunerea

vertebrelor cervicale; (fig. 5, 6) la 36 - 37 pentru

aosos.

-

Se poate obser

conturului mai radioopac al septurilor inter

acesta fiind un semn de activitate al paro

pacientei.

cateva aspecte importante: nivelul corticalelor

verticali ai pungilor parodontale infraosoase,

-oral,

tului interradicular, mai

ales la molarii superiori (exemplu 16), date

celei mai bune metode de tratament

(regenerativ sau rezectiv).

Fig. 5, 6.Patient P.A. Retro-dental-alveolar radiographs

Pacienta P.A. Radiografii retrodentoalveolare

This information is obtained after complete

exploration and interpretation of the results bycomputer-tomography and Dental CT program. telor prin programul Dental CT.


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For this purpose we used a Somatom

Emotion, Siemens device; the exploration was

done at Explore-Rx Center in Iasi,; Syngo

software (eFilm software from Merge eMed)

was used to measured bone density (in

Hounsfield units) and for measurement ofdistances. Section thickness was 1 mm (130 kV,

90mAs).

We used sections parallel to axe incremented

mm by mm, allowing bone defects measurement

of in subsequent sections (fig. 7-11).

Pentru acesta s-a folosit un aparat Somatom

Emotion, Siemens,explorarea s-a realizat la

Centrul Explora-Rx din Iasi, programul Syngo

(soft eFilm, de la Merge eMed) a fost utilizat

pentru masurarea densitatii osoase (in unitati

Hounsfield) si pentru masurarea distantelor.Grosimea sectiunilor a fost de 1mm ( 130 kV,

90mAs).

Am fo

-11 ).

Fig. 7. In which, plans are parallel to axe sections atthe upper jaw.

Planurile in care se fac sectiunile paraxiale, maxilar

superior

8 9

10 11

Fig. 8 - 10.Patient P.A. Sections parallel to axe show advanced bone loss at 11.

Sections in planes parallel to the hard palate,

with 1mm thick, made in 0.5 mm to 0.5 mm

from the apex of 11 to the cervical area (or

incised edge) allow the visualization of bone

defect morphology and depth of measurementby the number of sections. One can also observe

and intraosseous defect level 16 (fig. 12-28).

Processing program through the CT imaging

acquisitions Syngo (eFilm software from Merge

eMed) allowed and two-dimensional

reconstruction of successive plans, separated by

thickness of 2mm between them highlights the

superiority of the classical method,

ortopantomographics, alveolar lyses at level 12,

11, 21, 22, and also at 16-15 level.

Data provided by computer-tomography

examination is closest to the reality of intraosseous

defects and are summarized below (fig. 31, 32).

nivelul

marginii incizale) permit atat vizualizarea mo

profunzimii l

defectul infraosos de la nivelul 16 (fig. 12-28).

Programul de prelucrare a achizitiilor

imagistice CT prin programul Syngo (soft eFilm,

de la Merge eMed) a permis si reconstructia

bidimensionala in planuri succesive, la grosimi de

clasice, ortopantomografice, alveolizele de la

nivelul -15.

Datele oferite de examenul computer-

tomografic este cel mai apropiat de realitatea

intraoperatorie a defectelor infraosoase (fig. 31,

32).


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12 13

16 17

14 15

18 19

20 21

24 25

22 23

26 27

Fig. 12-27.Patient P.A. Horizontal CT sections

Fig. 29.Patient P.A. Plotting successive plans and 2D reconstruction of the upper jaw.

The method has provided valuable data that

have guided treatment towards a regenerative

therapy that required sampling the coagulummentoniere bone (fig. 33, 34).

Acesta a oferit date pretioase care au orientat

tratamentul spre o terapie regenerativa ce a

impus si recoltarea de coagulum osos din simfizamentoniera (fig. 33, 34).


7/9



Fig. 31, 32. Patient P.A. Probing reveals periodontal intra-operator interdental areas at 12- 11 and 21-22 of

periodontal defects intraosseous with two vertical bony walls, vestibular and palate

- -22

Fig. 33. Menton collection of bone area. Fig. 34. Coagulum bone

Fig. 35. Suture mentoniere donor area. Fig. 36. Realizarea aditiei la nivelul defectelor

infraosoase

Classic radiographic examination retro-

dental-alveolar at upper front group showed animprovement of periodontal support tissues

even though there are still apparent

unresorbable fragments in the combling areas.

The price of examination is high and, most

importantly, the patient receives significant

irradiation (2.8mSv for a CT cranial compared

with 0.5 mSv for an X-ray panoramic).

CT examination (axial and coronal sections)

has the disadvantage of artefacts caused by the

presence of metallic structures (see fig. 26) and

computing errors (alveolar diameter) caused by

the variable shape of dental arches.

Examenul radiografic clasic retro-

dentoalveolar la nivelul grupului frontal superiorarat t

parodontal, chiar dac se observ

neresorbite complet la nivelul zonelor de

comblaj (fig. 38, 39).

Costul examin

important, iradierea pacientului este semnificativ

(2,8 mSv pentru o CT cranian comparativ cu 0,5

mSv pentru o radiografie panoramic ).

de calcul (diametrul alveolar) cauzate de

a arcadelor dentare.


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Fig. 37. Access aesthetic flap Fig. 38, 39. Radiographic appearances at 11-21-22 at

12-11 at 3 months post-operator.

Aspect radiografic retrodentoalveolar la nivelul 12-11

si 11-21-22, la 3 luni postoperator

DISCUSSIONS

Ortopantomographics remains a guidance

examination for detection and control; it is a

comprehensive study, receiving the image on asingle system-dental-alveolar [1]. Its simplicity is

due to relatively mild positioning, coupled with

rapid implementation, low price and irradiation

recommended that as an initial examination in

periodontology because it allows overall

assessment of the proximal bone and

interradiculare the type of bone lyses (horizontal

or vertical), the topography of alveolar

destructions [2, 3].

The disadvantages are that it does not offer

information in connection with the bone atvestibular and oral areas of the teeth and,

neither on the morphology of intraosseous

lesions: number of vertical bone walls, extension

of intraosseous lesion, morphology of

interradiculare bone defect (see fig. 2).

Due to overlapping of anatomical formations

(cervical spine) or distortions from positioning,

on ortopantomographics some areas appear

blurred (upper and lower front group), for they

shall undertake retro-dental-alveolar or bite-

wing radiographs (interproximal).It is preferable to choose a device with long

cone technique using parallel planes method,

because it has many advantages: no deformation

of the teeth, no projection of neighbouring

structures, perfect view of lamina durra and

alveolar ridge, interdental and interradicular bone

defects. Exploring limits remain the same, since

both are bi-dimensional reflections of a three-

dimensional reality, so one of these dimensions of

space (depth) is inevitably lost [3, 4].

Computer-tomography (CT) and then spiralcomputer-tomography (spiral CT) and many-

orientare, depistar

dento-

ie, deoarece

alveolizelor [2, 3].

infraosoase, morfologia defectului osos

interradicular vezi fig. 2.

a-

-

dentoalveolare sau bite-wing (interproximale).

Este de preferat alegerea unui aparat cu con

crestei alveolare, a defectelor septurilor osoase

tridimensionale, deci una dintre dimensiunile

l


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slices CT type (MSCT) technology have

revolutionized exploration techniques by fine

sections achieved in axial and coronal plane, 2D

and 3D reconstruction in low time for acquiring

images, the quality of bone and dental imaging

that allows detailed exploration of intraosseousdefects: their depth, width, number of bone

walls, the vertical extent and spatial

configuration of pockets, morphology of

interradiculare alveolar loss [4, 5].

The method permits also quality evaluation

of bone support on the basis of Hounsfield

density.

CONCLUSIONS

Today, in periodontology, the clinical

examination and ortopantomographics orradiographies only do not provide sufficient data

to make a correct therapeutic decision,

especially in the case of periodontal intraosseous

pockets and interradiculare lesions combined

with intraosseous pockets.

Computer tomography examination

processed by dental CT program brings valuable

data in these cases, pointing to a better

therapeutic decision: regenerative or radical,

depending on the spatial architecture of bone

defects, the prognosis of the large lesions being

more reserved than the one of the narrow and

deep lesions, with several vertical bone walls.

-ul tip

plan

timpul redu

infraosoase serpiginoase, morfologia alveolizelor

interradiculare [4, 5].

CONCLUZII

retro-

interradiculare combinate cu pungi infraosoase.

Examenul computertomografic prelucrat prin

prognosticul leziunilor largi fiind mai rezervat

deca

REFERENCES

1. Barthe M, Marchal MF.-

Stomatologiques 1993; 181: 21-34

2. -maxillaire.Approche radio-clinique. Paris. Masson,

1995

3. -Cap. I: 26-30

4.5. www.osseosnews

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