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Radiographic Analysis
Radiographic Analysis
5
Periapical Survey these radiographs can assess the presence and
effect of root resorption.
Periapical radiographs give useful information
about caries, periodontal condition, periapical
pathology, shape of the roots, size of the teeth, Panoramic Radiograph
position of impacted teeth, and spatial location
of teeth not yet erupted. Measurements of the The panoramic radiograph gives a complete view
mesial-distal widths of the periapical images of of the dentition and supporting bones (White
nonerupted premolars and upper canines are and Pharoah 2004). The stage of development of
essential for the prediction of tooth size in the nonerupted teeth and the dental age of the patient
Hixon-Oldfather and Iowa mixed-dentition can be determined by rating root development of
space analyses. A periapical survey of a patient several teeth. The shape of the condyles of the
in the early mixed dentition is illustrated in mandible can be observed, and abnormal or
Figure 5.1. These radiographs give an accurate asymmetric shapes of the condyles can be noted
image of the roots that serve as a pretreatment and related to patient symptoms. Views of the
baseline for the posttreatment assessment of root relationship of nonerupted third molars to second
resorption. The pretreatment radiographs can molars and surrounding structures can help
also show the presence of root resorption before shape treatment planning decisions for these
treatment. A 16-inch-long cone paralleling or teeth.
right angle technique is recommended for taking Several panoramic radiographs illustrate dif-
the periapical radiograph. ferent developmental stages of growth, ankylo-
During treatment, periapical radiographs are sis, congenitally missing teeth, and impacted
used to monitor the position and movement of teeth in Figures 5.2 through 5.12. Figure 5.2
nonerupted teeth and the growth of the roots of shows the erupted primary dentition and all of
developing teeth. At the end of active treatment, the developing nonerupted permanent teeth,
except for the third molars. The early mixed
dentition is shown in Figure 5.3. At this stage of
Essentials of Orthodontics: Diagnosis and Treatment
by Robert N. Staley and Neil T. Reske development, the permanent incisors and first
© 2011 Blackwell Publishing Ltd. molars are erupted. In the late mixed dentition,
57
Figure 5.1. Periapical survey of the early mixed dentition. Arrows point to the tooth images measured for the revised Hixon-
Oldfather and Iowa tooth size prediction methods.
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Radiographic Analysis 59
Figure 5.9. Panoramic of a patient who lost tooth A prema- Figure 5.12. Panoramic of an early mixed dentition with a
turely, which allowed the mesial migration of the upper right supernumerary tooth (mesiodens) located between the maxil-
first molar that impacted the upper right second premolar. lary central incisors (arrow). (Courtesy of Dr. Samir Bishara.)
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Radiographic Analysis 61
Figure 5.10 illustrates the premature loss of the treatment. The radiograph can be repeated
mandibular left second primary molar in a late during the expansion of the arch to observe
mixed-dentition patient. Loss of the primary whether the midpalatal suture has opened and
molar allowed the mandibular left permanent how much it opened. Figure 5.13 is an occlusal
first molar to tip mesially, causing the impaction view of the patient illustrated in Figure 5.11.
of the mandibular left second premolar. An adult The canines are far forward on the palate, near
patient with both permanent maxillary canines the roots of the permanent incisors. Also note the
impacted on the palatal side of the arch is illus- image of a supernumerary tooth in the middle of
trated in Figure 5.11. Please note that the primary the palate between the canines. The supernumer-
maxillary canines were still retained in the mouth. ary tooth is a mesiodens that is undergoing
Figure 5.12 illustrates a mixed dentition patient resorption, a fate common to many of these
with a supernumerary tooth called a mesiodens teeth. Figure 5.14 shows impacted maxillary
located between the maxillary central incisors. second premolars in an adolescent patient. The
Note the 90-degree rotation of the maxillary left teeth are erupting toward the midline suture of
central incisor and the diastema between the the palate. Figure 5.15 illustrates the opening of
central incisors. the mid palatal suture of an adolescent patient
treated with a rapid maxillary expander. Note
the V-shaped opening of the maxillary suture
Occlusal Radiographs and the diastema created by the appliance. The
mandibular occlusal radiograph of an orthodon-
Maxillary and mandibular occlusal radiographs tic patient with cleidocranial dysostosis is shown
provide useful supplemental information on the in Figure 5.16. Note the presence of several
position of impacted teeth, especially canines and supernumerary teeth and the severely impacted
premolars (White and Pharoah 2004). A maxil- mandibular left permanent canine. The impacted
lary occlusal radiograph is taken as a pretreat- canine was located on the labial side of the alveo-
ment baseline view of the midpalatal suture lus and was brought into the arch through orth-
whenever a rapid maxillary expander is used in odontic treatment.
Figure 5.16. View of the mandibular arch of a patient with Figure 5.18. Lateral, lingual (cone beam computed tomogra-
supernumerary teeth and an impacted mandibular left canine phy) view of the lower left second premolar.
(arrow).
Cone Beam Radiographs through the lower second premolars that gives
an excellent view of the developing lower right
Cone beam radiographs are shown of a patient second premolar and the supernumerary in the
who had ectopic lower second premolars and a upper right palate. Figure 5.18 is a sagittal view
maxillary supernumerary tooth. A conventional of the left mandible illustrating the development
panoramic radiograph showed the ectopic teeth of the lower left second premolar. Figure 5.19 is
through their long axes, not showing where the a lingual volumetric view of the lower right
crowns were located and how long the roots had second premolar. Figure 5.20 is a lingual volu-
grown. The supernumerary tooth was located in metric view of the lower left second premolar.
the upper right palate alongside the canine and Figure 5.21 is an excellent lingual volumetric
premolars. Figure 5.17 is a coronal section view of the supernumerary tooth.
Figure 5.19. Lingual volumetric (cone beam computed tomography) view of the lower right second premolar.
Figure 5.20. Lingual volumetric (cone beam computed tomography) view of the lower left second premolar.
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64 Essentials of Orthodontics: Diagnosis and Treatment
Figure 5.21. Lingual palatal volumetric (cone beam computed tomography) view of the supernumerary tooth in the upper right
canine region.
outline of the pituitary fossa and (2) porion is Cephalometric Point Locations
located at the most superior point on the ear rod.
Some points are more easily and reliably located The points described next are illustrated in Figure
than others (Baumrind and Frantz 1971a, 5.23 (Athanasiou 1995; Krogman and Sassouni
1971b). For example, nasion is relatively easy to 1957).
locate compared to posterior nasal spine. Sella (S) is located in the center of the outline
Location of a point may be easier in one plane of the pituitary fossa. Locating the point before
of space than in the other. The vertical position tracing the shadow of the anterior and posterior
of the posterior nasal spine is more easily located clinoid processes and floor of the fossa that sur-
than its AP position. round the pituitary gland is probably more accu-
In bilaterally symmetric faces, facial structures rate than locating the point after tracing the sella
on the left side, including teeth, are superior and turcica.
posterior to structures on the right side. Nasion (Na) is located at the most inferior,
Permanent first molars on the left side are usually anterior point on the frontal bone adjacent to the
traced. The images of the right and left sides of frontonasal suture. Again, point location should
the mandible are bisected and traced as one precede tracing of the bony outlines.
bisection line. Orbitale at the inferior border of Orbitale (Or) is located on the lowermost
the orbit is located between the images of the point of the bony orbit outline. When both right
right and left orbits. The most anterior upper and and left orbital outlines are visible, orbitale is
lower central incisors are traced. located at the bisection of the two orbit outlines.
Radiographic Analysis 67
the mandibular plane to a line passing through incisor. As the incisors become more protrusive,
the anterior cranial base. the angle decreases, and as the incisors lose incli-
Anterior face height is measured from nasion nation, the angle increases (Fig. 5.27).
to menton (N:Me). An adjustment for enlarge- Frankfort horizontal plane–to–mandibular
ment, averaging about 12% for traditional incisor angle (FMIA) relates the axial inclination
analog cephalometric radiographs, is made by of the most labial mandibular incisor to the
multiplying any measured distance by 0.88. Frankfort horizontal plane (Fig. 5.27). This
Digital cephalograms can approximate life size, angular relationship is a reliable method for
and distance measurements can be taken directly assessing the inclination of the lower incisor if
from the radiograph without needing an adjust- porion and orbitale are located accurately.
ment for enlargement. Mandibular incisor–to–mandibular plane
angle (IMPA) relates the axial inclination of the
most labial incisor to the mandibular plane (Fig.
Dental Angles 5.27). This angle is affected by the morphology
of the mandible. As the angle between the man-
Maxillary incisor–to–S-N plane angle relates the dibular plane and sella-nasion plane decreases,
axial inclination of the most labial maxillary the IMPA angle becomes larger. As the angle
incisor to a line passing through the anterior between the mandibular plane and sella-nasion
cranial base (Fig. 5.27). plane increases, the IMPA angle decreases. The
Maxillary incisor–to–mandibular incisor angle inverse relationship must be taken into account
relates the axial inclination of the maxillary when using this angle to assess the inclination of
incisor to the axial inclination of the mandibular the lower incisor.
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Radiographic Analysis 71
REFERENCES
occlusal plane just described. A line drawn
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at the gonial angles (the greatest dimension London: Mosby-Wolfe.
across the mandible at the gonial angle) can be Baumrind, S., and Frantz, R. 1971a. The reliability of
drawn to assess the deviation of the lower dental head films measurements, 1. Landmark identifica-
tion. Am. J. Orthod. 60:111–127.
midline from the middle of the chin (Fig. 5.31).
Baumrind, S., and Frantz, R. 1971b. The reliability of
The chin midline is estimated by dropping a per-
head films measurements. 2. Conventional and
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Analog versus Digital Radiography their significance in treatment and prognosis. Am.
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Digital radiography is an advancement in den- Kantor, M. L. 2005. Dental digital radiography, more
than a fad, less than a revolution. J. Am. Dent.
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however, digital radiography will eventually Kovacs, I. 1971. A systematic description of dental
replace film technology. Digital radiography is roots. In Dental morphology and evolution (pp.
amenable to immediate viewing, standardized 225–230), ed. A. A. Dahlberg. Chicago: University
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74 Essentials of Orthodontics: Diagnosis and Treatment
Krogman, W. M., and Sassouni, V. A. 1957. Syllabus Tweed, C. H. 1962. Was the development of the
in roentgenographic cephalometry. Philadelphia: diagnostic facial triangle as an accurate analysis
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