Osseous Craters

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PAR I 5 ■ treatment ofVerioihatat Diseuse

Long Cone Paralleling Technique Meaning

Fig. 31-3 Long cone paralleling technique and bisection of the angle technique compared. A, Long cone technique. Radiograph ot dried specimen B, Long cone technique. Same specimen. The smooth wire is on the margin ot the facial plate and the knotted wire is on the lingual plate to show their relative positions C, Bisection of the angle technique. Same specimen. D, Bisection of the angle technique Same specimen Both bone margins are shifted toward the crown, the facial margin (smoolh wire) more than the lingual margin (knotted wire), creating the illusion that the lingual bone margin has shifted apically. (Courtesy Dr. Benjamin Patur, Hartford, CT.)

Fig. 31-3 Long cone paralleling technique and bisection of the angle technique compared. A, Long cone technique. Radiograph ot dried specimen B, Long cone technique. Same specimen. The smooth wire is on the margin ot the facial plate and the knotted wire is on the lingual plate to show their relative positions C, Bisection of the angle technique. Same specimen. D, Bisection of the angle technique Same specimen Both bone margins are shifted toward the crown, the facial margin (smoolh wire) more than the lingual margin (knotted wire), creating the illusion that the lingual bone margin has shifted apically. (Courtesy Dr. Benjamin Patur, Hartford, CT.)

Perialveolar Wiring

Fig. 314 Distortion by oblique projection. A, Long cone technique. The smoolh wire is on the facial bony plate, the knotted wire on the lingual. Note the knot (arrow) near the center of the distal root of the first molar, which shows bifurcation involvement B, Long cone technique. Cone is placed distally, projecting the rays mesially and obliquely. The oblique projection shilts the image ol all structures mesially. The structures closest to the cone shift the most. This creates the Illusion that the knot (arrow) has moved distally. Note that the bifurcation involvement shown in A is obliterated in B. (Courtesy Dr. Benjamin Patur, Hartford, CT.)

Fig. 314 Distortion by oblique projection. A, Long cone technique. The smoolh wire is on the facial bony plate, the knotted wire on the lingual. Note the knot (arrow) near the center of the distal root of the first molar, which shows bifurcation involvement B, Long cone technique. Cone is placed distally, projecting the rays mesially and obliquely. The oblique projection shilts the image ol all structures mesially. The structures closest to the cone shift the most. This creates the Illusion that the knot (arrow) has moved distally. Note that the bifurcation involvement shown in A is obliterated in B. (Courtesy Dr. Benjamin Patur, Hartford, CT.)

lamina tluru, crcstul railioilensity, si/c ami shape of the mctlullury spaces, ami height ami contour of the hone I he interdental septa may be reduced in height, with the crest horizontal and perpendicular to the long axis ol the adjacent teeth d ig. 31-5), or they may have angular or arcuate defects (Fig. 31-6). Ihe former condition is called hori/onhtl hone loss, the latter angular or vertical hone loss (see Chapter 23).

Radiographs do not indicate the internal morphology or depth ol the craterlike interdental defects, which ap-pear as angular or vertical defects, nor do they reveal the extent of involvement on the facial and lingual surfaces. There are several reasons for this. Facial and lingual surface bone destruction is obscured by the dense root structure, and bone destruction on the mesial and distal root surfaces may be partially hidden by a dense mylo-

Radiographic Mils in the Diagnosis of Periodontal Disease ■ ( HUM IK \\ 457

Periodontal Disease Trifurcation
Fig. 315 Generalized horizontal bone loss.

hyoid ridge d ig. 31-7). In most cases it can be assumed that bone losses seen interdentally continue in either the facial or lingual aspects creating a troughlike lesion. I lie true lesion can only be detected by clinically probing the defect.

Dense cortical plates on the facial and lingual surfaces of the interdental septa obscure destruction that occurs in the intervening cancellous bone. I bus it is possible to have a deep crater in the bone between the facial and lingual plates without radiographic indications ol its presence. For destruction of the interproximal cancellous bone to be recorded radiographically, the cortical bone must be involved. A reduction of only 0.5 or 1.0 nun in the thickness of the cortical plate is sufficient to permit radiographic visualization of destruction of the inner cancellous trabcculae.1*

Interdental vertical lesions in the posterior area with thick facial or lingual bone may not be isolated in the in terdental area but may continue facially or lingually or both to form a troughlike defect that cannot be seen radiographically. These lesions may terminate on either the radicular surface or may communicate with the adjacent interdental area to form one continuous lesion (Fig. 31-8).

Fig. 31-9 shows two adjacent interdental lesions connecting on the radicular surface to form one interconnecting osseous lesion. Along with clinical probing of these lesions, the use of a radiopaque pointer placed in these radicular defects will demonstrate the extent of the bone loss.

liutta percha packed around the teeth increases the usefulness of the radiograph lor detecting the morphologic changes of osseous craters and involvement of the facial and lingual surfaces (Fig. 31-10). However, this is a cumbersome technique and is seldom performed. Surgical exposure and visual examination provide the most

4 58 PAKT 5 ■ Treatment of Periodontal Disease

Osseous Craters
Fig. 31-6 Angular bono loss on firs! molar with involvement of the lure alion.
Reduction Mylohyoid Ridge
Fig. 31-7 Angular bone loss on mandibular molar partially obscured by dense mylohyoid ridge.

definitive information regarding the bone architecture produced bs periodontal destruction.7"

Radiographic Changes in Periodontitis

I he following is the sequence of radiographic changes in periodontitis and the tissue changes that produce them:

I. bu/./incs.s inul ii break in the continuity of the lamina iliihi at the mesial or distal aspect of the crest of the interdental septum have been considered as the earliest radiographic changes in periodontitis dig. 31-11), rhese result from the extension of gingival inflammation into the bone causing widening of tfie vessel channels and a reduction in calcified tissue at the septal margin.

Crateres Interdentales
Fig. 31-8 A and B, Interdental lesion that extends to the facial or lingual surfaces in a trough-like manner.

I hese changes are however highly dependent on the radiographic technique (angulation of the tube, placement of the film) and on anatomical variations (thickness and density of the interdental bone, position of adjoining teethi. No correlation has been found between crestal lamina dura in radiographs and the presence or absence of clinical inflammation, bleeding on probing, periodontal pockets, or loss of attachment.11 4 therefore it can be concluded that the presence of an intact crestal lamina dura maybe an indicator of periodontal health, whereas its absence lacks diagnostic relevance.'

2. \ wedge-shaped radiolucent men is formed at the mesial or distal aspec t of the crest ol the septal bone (see Fig. 31-11, l<). rhe apex of the area is pointed in the direction ol the root I his is produced by resorption of the bone of the lateral aspect of the interdental septum, with an associated widening of the periodontal space.

3. I'he destructive process extends across the crest of the interdental septum and the height is reduced, Fingerlike radiolucent projections extend troin the erest into the septum (see Fig. 11-11, ( i. I he radiolucent projections into the interdental septum are the result of the deeper extension of the inflammation into the bone. Inflammatory cells and fluid, proliferation of connective tissue cells, and increased osteoclasis cause increased bone resorption along the endosteal margins ot the medullary spaces. I he radiopaque projections, separating the radiolucent spaces, are the composite images of the partially eroded bony trabeculae.

Riitliognifthii \iils in Hic L>iuwto\i\ ti/ l*t'ri<iiloiitiil PisciiM' ■ CH M'JT K tl 459

Interproximal Crater Image

Fig. 319 A, Interdental mesial and distal lesions B, Facial or lingual outlines of actual lesion C, Occlusal view of lesion D, Actual radiograph of mesial and facial lesions.

Interdental Craters
Fig. 51 10 Gutta percha aids in detecting hone defects. A, Gutta percha packed around teeth shows inte» proximal and facial and lingual bone loss B, Same area without gutta percha gives little indication of the ex tent of hone involvement.

4. The height of the interdental septum (see l ig. U-l 1, D) is progressively reduced by the extension of inflammation and the resorption of bone.

Radiographic Appearance of Interdental Craters

Interdental craters are seen as irregular areas of reduced radiopacity on the alveolar bone crests-''*; they are generally not sharply demarcated from the rest of the bone, with which they blend gradually. Radiographs do not ac curately depict the morphology or depth ol interdent.il craters, which sometimes appear as vertical delects.

Radiographic Appearance of Furcation Involvements

Definitive diagnosis ol lunation involvement is made In clinical examination, which includes carelul probing with a specially designed probe (Nabers probe). Radiographs are helpful but show artifacts that make it

Prob NabersInterdental Septa

Fig. 31-11 Radiographic changes in periodontitis A, Normal appearance ol interdental sepia. B, Fu//iness and a break in the continuity o the lamina dura at the crest of the bone distal to the central incisor (left) There are wedge-shaped radiolueent areas at the crests of the other interdental septa C, Radiolucent projec tions from the crest into the interdental septum indicate extension of destructive processes D, Severe bone loss.

Fig. 31-11 Radiographic changes in periodontitis A, Normal appearance ol interdental sepia. B, Fu//iness and a break in the continuity o the lamina dura at the crest of the bone distal to the central incisor (left) There are wedge-shaped radiolueent areas at the crests of the other interdental septa C, Radiolucent projec tions from the crest into the interdental septum indicate extension of destructive processes D, Severe bone loss.

possible for furcation involvement to be present without detectable radiographic changes.

.Is it general rale, bone loss is always greatei than it op-pears in the radiograph. Variations in the radiographic technique may obscure the presence and extent of furcation involvement. A tooth may present marked bifurcation involvement in one film (lig. U 12, .4) hut appear to be uninvolved in another (see lig. .51-12, /J). Radiographs should be taken at different angles to reduce the risk of missing furcation involvement.

I he recognition of large, clearly defined radiolucency in the furcation area presents no problem (see l ig. i 1-12, I), but less clearly defined radiographic changes pro duced by furcation involvement are often overlooked. To assist in the radiographic detection ol furcation involvement, the following diagnostic t riteria are suggested:

1. I he slightest radiographic change in the furcation area should lie investigated clinically, especially if there is bone loss on adjacent roots dig. 3I IJ).

2. Diminished radiodensity in the furcation area in which outlines of bony trabeculae are visible (Fig. 31-14) suggests furcation involvement.

3. Whenever there is marked bone loss in relation to a single molar root, it may be assumed that the furcation is also involved (Figs. 31-15 and JI-16).

Ktiifuigruphii Aith in the Diagnosis of t'erioiloHtut Disease ■ C 11 Al*'l I R il 4(> I

Furcation Involvement ImagesFuzziness Crestal Bone
Fig. 31-13 Early furcation involvement suggested by fuzziness in the bifurcation of the mandibular first molar, particularly when associated with bone loss on the roots

Fig. 31-12 A, Furcation involvement indicated by triangular radi-olucency in bifurcation area of mandibular first molar. The second molar presents only a slight thickening of the periodontal space in the bifurcation area. B, Same area, different angulation. The triangular radiolucency in the bifurcation of the first molar is obliterated, and involvement of the second molar bifurcation is apparent.

Image Third Molar AngulationFurcation Involvement Perio Disease

Fig. 31-14 Furcation involvement of mandibular first and second molars indicated by thickening of periodontal space in furcation area. The furcation of the third molar is also involved, but the thic k ening of the periodontal space is partially obscured by the external oblique line.

Fig. 31-12 A, Furcation involvement indicated by triangular radi-olucency in bifurcation area of mandibular first molar. The second molar presents only a slight thickening of the periodontal space in the bifurcation area. B, Same area, different angulation. The triangular radiolucency in the bifurcation of the first molar is obliterated, and involvement of the second molar bifurcation is apparent.

Fig. 31-15 Furcation involvement with bone loss on the distal root ol the first molar, assoc iated

Fig. 31-14 Furcation involvement of mandibular first and second molars indicated by thickening of periodontal space in furcation area. The furcation of the third molar is also involved, but the thic k ening of the periodontal space is partially obscured by the external oblique line.

462 PAR I S * treatmentof Periodontal Diseasi

First Molar Ray Angle

Fig. 31-16 Furcation involvement ol the first molar partially oh Fig. 31-18 Typical radiographic appearance of periodontal obscured by the radiopaque lingual root. The horizontal line across scess on right central incisor, the distobuccal root demarcates the apical portion (arrow), which is covered by bone, from the remainder of the root, where the bone has been destroyed.

Fig. 31-16 Furcation involvement ol the first molar partially oh Fig. 31-18 Typical radiographic appearance of periodontal obscured by the radiopaque lingual root. The horizontal line across scess on right central incisor, the distobuccal root demarcates the apical portion (arrow), which is covered by bone, from the remainder of the root, where the bone has been destroyed.

Ray Periodontal Abscess

Radiographic Appearance of the Periodontal Abscess

The typical radiographic appearance of the periodontal abscess is that of a discrete area of radiolucency along I he lateral aspect of the root d igs. 31-17 and 31-18). However, the radiographic picture is often not typical {Fig. 41-19) because of many variables such as the following:

1. the stage of the lesion. In the early stages the acute periodontal abscess is extremely painful but presents no radiographic i hanges.

2. I'lte extent of hone destruction and the morphologic changes o/ lite hone.

I'lte locution of the abscess. Lesions in the soft tissue wall of a periodontal pocket are less likely to produce radiographic changes than those deep in the supporting tissues. Abscesses on the facial or lingual surface are obscured by the radiopacity of the root; interproximal lesions lire more likely to be visualized radiographically.

Therefore the radiograph alone cannot be relied on for the iliagnosis of it periodonttil abscess.

Fig. 3117 Radiolucent area on the lateral aspect of the root with chronic periodontal abscess.

Radiographs and Clinical Probing

Regenerative and resective flap designs and incisions require prior knowledge of the underlying osseous topography. Careful probing of these pocket areas after scaling

Ruiiingraphii Aiils in the Diagnosis of reriodttntiil Diseuse • ( HAITI-.K H 463

Periodontal Disease Probing
Fig. 31-19 Chronic periodontal abscess. A, Periodontal abscess in the right central and lateral incisor area B, Extensive bone destruction and thickening of the periodontal ligament space around the right central incisor
Periodontitis Chronica Fibrosa

Fig. 31-20 A, Radiograph of maxillary cuspid. Does not show facial bone loss. B, Radiograph of same maxillary cuspid with gutta percha points placed in the facial pocket to indicate bone loss.

and root planing often require local anesthesia and definitive radiographic evaluation of the osseous lesions. Radiographs taken with periodontal probes or other indicators (e.g., Hirschfeld pointers) placed into the anesthetized pocket show the true extent of the bone lesion. As indicated previously, the attachment level on the radicular surface or interdental lesions with thick facial or lingual bone cannot be visualized in the radiograph. The use of radiopaque indicators is an efficient diagnostic aid for the clinician to better visualize every aspect of the defect. Figs. 31-20. .1 and H, are examples of probes placed in pockets to indicate the bone level.

Radiographic Changes in Localized, Aggressive Periodontitis

Juvenile periodontitis is characterized by a combination of the following radiographic features:

1. Bone loss may occur initially in the maxillary and mandibular incisor and/or first molar areas, usually bilaterally, and results in vertical, arclike destructive patterns (I ig. 31-21 ).

2. Loss of alveolar bone may become generalized as the disease progresses but remains less pronounced in the premolar areas.

Local Aggressive Periodontitis

I ¡9. 31-21 Localized aggressive periodontitis. The accentuated hone destruction in the anterior and lirst molar areas is considered to he characteristic of this disease

464 l'AIM 5 ■ Treatment ofPeriodontal Disease

I ¡9. 31-21 Localized aggressive periodontitis. The accentuated hone destruction in the anterior and lirst molar areas is considered to he characteristic of this disease

Periodontics Trauma From Occlusion

Fig. 51 22 Widened periodontal space caused by trauma from occlusion Note the increased density of the surrounding bone caused by new bone formation in response to increased occlusal forces.

Radiographic Changes in Trauma from Occlusion

Trauma from occlusion can produce radiographically detectable changes in the lamina dura, morphology of the alveolar crest, width of the periodontal space, and density of the surrounding cancellous bone.

Traumatic lesions manifest themselves more clearly in faciolingual aspects, because mesiodistally. the tooth has the added stability provided by the contact areas with adjacent teeth. Therefore slight variations in the proximal surfaces may indicate greater changes in the facial and lingual aspects. The radiographic changes listed below arc not pathognomonic of it noma (nun occlusion ami have to he interpreted in combination with i linical findings, particularly tooth mobility, presence of wear facets, pocket depth, and analysis of occlusal contacts and habits.

I he injury phase of trauma from occlusion produces a loss of the lamina dura that may be noted in apices, furcations, and/or marginal areas I bis loss of lamina dura results in widening of the periodontal ligament space (l ig. 31-22). I his change, particularly when incipient or circumscribed, may easily be confused with technical variations due to x-ray angulation or malposition of the tooth; it can be diagnosed with certainty only in radiographs of the highest quality.

The repair phase of trauma from occlusion results in an attempt to strengthen the periodontal structures to better support the increased loads. Radiograph ica 11 y, this is manifested by a widening of the periodontal ligament space, which may be generalized or localized.

Although microscopic measurements have determined that there are normal variations in the width of the periodontal space in the different regions Of the root.

Radiographic Mils in the Diagnosis of I'emutontal Disease ■ CH API I K II 465

these are not generally detected in radiographs. When variations in width between the marginal area and mid-root or between the mid root and apex are detected, it means that the tooth is being subjected to increased forces. Successful attempts to reinforce the periodontal structures by widening of the periodontal space is accompanied by increased width of the lamina dura and sometimes by condensation of the perialveolar cancellous hone.

More advanced traumatic lesions may result in deep angular hone loss, which, when combined with marginal inflammation, may lead to intrabonv pocket formation. In terminal stages these lesions extend around the root apex, producing a wide radiolucent periapical image (cavernous lesions)

Root resorption may also occur as a result of excessive forces on the periodontium, particularly those caused by orthodontic appliances. Although trauma from occlusion produces many root resorption areas, they are usually of a magnitude insufficient to be detected radiograph ica II y.

Additional Radiographic Criteria in the Diagnosis of Periodontal Disease

The following diagnostic criteria can be used to aid in the diagnosis of periodontal disease:

Radiopaque horizontal line across the roots. This line demarcates the portion of the root where the labial and/or lingual bony plate has been partially or completely destroyed from the remaining bone-supported portion (Fig. 31-23). Vessel canals in the alveolar hone. HirschfcldH described linear and circular radiolucent areas produced by interdental canals and their foramina, respectively (1 ig. 31-24). These canals indicate the course ot the vascular supply of the bone and are normal radiographic findings. The radiographic image of the canals is often so prominent, particularly in the anterior region of the mandible, that they might be confused with ra-diolucency resulting from periodontal disease. Differentiation between treated and untreated periodontal disease. It is sometimes necessary to determine whether the reduced bone level is the result of periodontal disease that is no longer destructive (usually after treatment and proper maintenance) or if destructive periodontal disease is present. Clinical examination is the basic determinant. However, radiographically detectable alterations in the normal clear-cut peripheral outline of the septa are corroborating evidence ot destructive periodontal disease.

Skeletal Disturbances Manifested in the Jaws

Skeletal disturbances may produce changes in the jaws that affect the interpretation of radiographs from the periodontal perspective. Destruction of tooth-supporting bone may occur in the following diseases:

Osteitis fibrosa cystica (Recklinghausen's disease ot bone) develops in advanced primary or secondary hyperparathyroidism and causes osteoclastic resorption of

Osteitis Fibrosa Cystica
Fig. 31-23 Horizontal lines across the roots ol the central incisors (arrows). The area ol the roots below the horizontal lines is partially or completely denuded of the facial and/or lingual bony plates.
Advanced Periodontal Disease
Fig. 31 24 Prominent vessel canals in the mandible.

bone with librous replacement and hemorrhage with hemosiderin deposition, creating a mass known as brown tumors (see Figs. 12-1 and 12-2). It often appears as a cystic lesion of the jaw. Ibis disease results in a diffuse granular mottling, scattered "cyst-like" radiolucent areas throughout the jaws, and a

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Responses

  • Heidi
    Is bone loss more on approximal or facial?
    8 years ago
  • saba tewelde
    What is triangular shape radiolucency on root furcation area?
    7 years ago

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