Prepared by: Houssam Ali

Submitted to: Dr.Nayer El Saad

Dental X-Ray Identifications

Radiology is the study or the science of x-ray radiations as used in dentistry.

Dental imaging allows the dental radiographer to identify conditions that are
clinically undetectable. So a clinical examination without dental imaging may limit
the dentist with few information. Dental images have many uses:
 Prognosis
 Diagnosis
 Disease detection
 Identification of dental materials, restorations and foreign objects
Dental imaging enables the dentist to view dental materials, restorations and to
identify and locate foreign objects. Many factors affect the appearance of these
material, such as the thickness, atomic number, density, degree of radiopacity,
contour, outline, size. However, some of these material require additional clinical
info to be identified, so it is important to interpret the dental images with the
presence of patient.
There are several types of dental radiograph:
1. Intraoral radiograph:

i. Periapical radiographs: covering the roots, usually used to detect

periodontal diseases… (Fig.1)
ii. Bite-wing radiographs: covering the crowns and its usually used to
detect interproximal caries… (Fig.2)
iii. Occlusal radiographs: used for the examination of buccolingual
lesions and impacted teeth… (Fig.3)

2. Extraoral radiographs:

i. Panoramic radiographs: by which the entire mouth is

captured. (Fig.4)
ii. Lateral cephalograms: to obtain craniofacial images. (Fig.5)

Fig.(1): periapical radiograph of maxillary malors pictured by the student Houssam Ali
……………………………………….at Beirut Arabe University dental clinics.
Fig.(2): Bite-wing radiograph. Fig.(3): occlusal radiograph.

Fig.(5): cephalometric radiographs. Fig.(4): panoramic radiograohs.

The aim of this chapter is to differentiate between different dental materials,

restorations and foreign objects seen by dental image.

Difference between radiopaque and radiolucent bodies.

Radiopaque objects don’t allow the passage of light, therefor they appear as a
white spots on x ray dental images (metals), whereas, radiolucent objects allow
the passage of light through them and so they appear as a black spot (plastics).
Abstract
When the radiographic density of restorative material is higher or somehow
equal to that of enamel, the presence of overhangs and defects directly near to a
filling becomes easy to detect. The density of 21 glass ionomer materials was
compared with the density of aluminium, dentine, enamel and amalgam after
being measured in the present study. The requirement stated by many
investigator were fulfilled because most materials were more radiopaque than
enamel. The material with low density have to be used in anterior teeth as the
filling can be examined clinically more easily. They better not be used under a
proximal filling, as a base in order for the diagnosis of recurrent caries not to give
a false positive result.i

I. Restorations
We can identify on dental images a variety of restorative materials
including gold, porcelain, amalgam, stainless steel, composite and acrylic.
As metallic restorations absorb x-rays, very little radiation comes in contact
with the receptor. Thus, on a dental image, the metallic restorations appear
radiopaque.
Non metallic restorations may differ from radiolucent to slightly radiopaque
and that would be related to the density of the material. Examples of the
non metallic restorations are: porcelain which is the least radiolucent and
most dense, and acrylic which is the most radiolucent and least dense.

1) Amalgam restorations:
There is many restorative material used in dentistry, however, the most common
is “amalgam”. Dental amalgam or silver amalgam is a mixture of metal alloy (tin,
silver, copper, mercury and other trace elements like zinc, palladium and indium)
that has been the material of choice in dentistry for more than 150 years due to
its durability, ease of application and its low cost. Amalgam appears completely
radiopaque on a dental image as it absorbs the x-ray beams and prevents it from
reaching the receptor.it can be detected in a variety of sizes, shapes and location
on dental image. (Fig.6) (Fi.22)
 i. One an multi surface amalgam restoration

One surface amalgam can be differentiated from multi-surface amalgam in two

ways. One, where one-surface amalgam restoration appearance is small, distinct,
void or round radiopacities (Fig.7), whereas larger multi-surface or two surface
amalgam restoration appearance is radiopaque which are detected by their
irregular outlines or borders (Fig.8). Multi-surface amalgam restorations may be
seen on any tooth surface where as one surface amalgam is limited to be on the
lingual, buccal or occlusal surfaces.

ii. Amalgam overhangs

A definition of amalgam overhangs would be that they are extensions of

amalgam found beyond the crown portion of a tooth in the interproximal
region. Moreover, if the amalgam was improperly placed around a tooth
before condensing the amalgam restoration, the result would be an
amalgam overhang.
On a dental image, overhangs appear radiopaque and thus easy to
visualize. It has many side effects like disrupting the natural cleansing
contours of the tooth, trapping food and laque, and contributing to bone
loss. Removing amalgam overhangs and replacing them with a restoration
of better contour prevents destruction of interproximal bone. (Fig.9)

iii. Amalgam fragments

During restoration, amalgam fragments are those fragments embedded

between adjacent soft tissue. They appear as a dense radiopacities with
irregular borders on dental images (Fig.10). Amalgam tattoo may be formed
when amalgam fragments are into soft tissue while placing or removing
amalgam restoration.(Fig.11)
Fig.(6): amalgam restoration class 1.

Fig.(7): one surface amalgam.

Fig.(8): multi surface amalgam restorations. Fig.(9): amalgam overhangs.

 Fig (11): amalgam tattoo.
Fig (10): amalgam fragments.

2) Gold restorations:

Metallic restorations are difficult to be differentiated on dental imaging.

However, gold which appears completely radiopaque with rounded borders
can be differentiated from amalgam restoration. With the presence of the
patient, oral examination can indicate whether the material used is
amalgam or gold. (Fig.12)

i. Gold bridge and crowns

Large radiopaque restoration with regular borders and smooth contour that
are similar to the gold onlay and inlay. (Fig.13)

ii. Gold foil restoration

As an amalgam one surface restoration, gold foil restoration appears as a

small round radiopacity. Two surface restoration appears similar to a gold
inlay with regular and smooth margins or slightly irregular as a two surface
amalgam restoration (Fig.14).
Fig.(12): gold restorations.

Fig.(13): fixed free fixed gold bridge restoration.

Fig.(14): one surface and two surface gold foil restorations.

3) Chrome crown and stainless steel restorations

Chrome crown and stainless steel restorations are premanufactured and
commonly used as restorations for the time being. These crowns are slim
and don’t take in dental x-rays to a level that amalgam, gold and another
cast metals do. Both chrome crown and stainless steel resulted in
appearing radiopaque even though not a slowly radiopaque as amalgam or
gold. Since these two restorations are premade, the margins and the
outlines look very normal generally the crowns aren’t formed fitly to the
cervical portion of the tooth and therefore don’t appear to fit the tooth.
Restorations that aren’t formed in a tooth shape may lead to periodontal
problems due to food crunch to gingival bleeding or a bone loss. (Fig.15)

Fig.(15): stainless steel crown that are less radiopaque than other metals restoration with
margins that are not formed fitly to the cervical portion.

4) Post and core restorations

Restorations of the post and core may be located in teeth managed with
endodontic therapy. They are cast metal and looks like radiopaque as
amalgam or gold. In addition to appear, it is core share represent the
prepared share of the crown, while the post portion elongatevinto the pulp
canal. (Fig.16) (Fig.22)
 Fig.(16): post and core radiopaque restorations.

5) Porcelain restorations

On dental imaging, porcelain restorations looks radiopaque, while like

metallic ones appear fully radiopaque, and the porcelain ones are a little
radiopaque to resemble the dentin radiodensity. (Fig.17)
A study was conducted to determine the radiopacity of CADCAM blocks using
digital radiograph.
2 mm thickness of 9 different ceramic blocks was compared with specimens
obtained from molars and premolars. ImageJ software is used to analyze the
images. Results show that most of blocks had higher radiopacity than dentin. ii
  All porcelain crown and bridges

On dental imaging, all porcelain bridge and crown look a little radiopaque.
The prepared tooth that is contoured by a slim radiopaque line that could
be evident through a crown that is radiopaque porcelain. It represents
cement or other dental adherent materials used to stick the crown to the
tooth. All porcelain bridge has a radiodensity that appear similar to that of
the crown. (Fig.18)

 Porcalian fused to metal

PFTM crown has two components when seen on a dental image. These
components seems fully radiopaque, while the porcelain ones looks a little
radiopaque. Its radiodensities bridge similar to that viewed in the PFTM
crowns. (Fig.19) (Fig.22)
Very important video comparing porcelain crown with full metallic crown
and PFM crown, showing the advantages of ceramics.
( https://www.youtube.com/watch?v=E6qUb-QL4S4)

6) Composite restorations

It may differ in appearance from radiolucent to a little radiopaque when

shown on dental image depending on the complex of the composite
materials. Radiopaque fillers may be added to some composite materials.it
takes visual and digital examination to the tooth to represent restoration.
(Fig.20)

7) Acrylic restorations
They are used as a temporary filling or crown. Acrylic is the least dense of
all the non metallic restorations and appears a bite radiopaque on dental
image.

iii
 Fig.(17): porcelain bridge.

Fig.(18): less radiopaque porcelain crown (near to

the radiopacity of the tooth. Red circle marking the
cement line.
 Fig.(19): PFM (porcelain fused to metal) crown.

Fig.(20):
different
types of composite fillings with different
radiopacities.
II. Identification of materials used in dentistry

There is a variety of materials used in dentistry where each is used for a

specific reason as they are also related to the specialty that requires the
material. On dental images, materials used by practitioners in restorative
dentistry, prosthodontics, endodontics, orthodontic and oral surgery can be
seen and noticed.

1) Restorative dentistry base materials

Base materials which are constituted of zinc phosphate cement and zinc
oxide eugenol paste are used as cavity liners in order to protect the pulp of
the tooth. They are placed on the floor of a cavity preparation. Then, a
restorative material, like amalgam, is placed over the base material.
Although base materials appear radiopaque, they are still less radiopaque
than amalgam (Fig. 21). Metallic pins are used to enhance the retention of
amalgam or composite. They appear on a dental images as screw-shaped or
cylindrical radiopacities. (Fig.22)

Fig.(21): pulp capping by MTA and

Bodentine having different radiopacities.

2) Materials used endodontics

 Gutta Percha
This material is used to fill the canals of the pulp as it is a rubber like
material. Similar to base materials, Gutta Percha appears radiopaque.
However, it is less radiopaque than metallic restorations. (Fi.22)

 silver points
similar to Gutta Percha, the silver pints are used to fill the canal of
the pulp. Silver points and metallic material are alike in the way they
appear highly radiopaque. However, silver points look more
radiopaque than Gutta percha. (Fig.23)

3) Materials used in prosthodontics

 On dental images, complete and removable partial denture might be
occasionally noticed. Furthermore, complete and removable partial
denture may vary in appearance which depend on the base material
and type of denture teeth used. Before dental images are exposed,
doctors should instruct patients to remove all complete and partial
denture. In case they weren’t removed, they might obscure some
info related to adjacent teeth and underlying bone.
In some cases, the decision is made to keep a denture in place during
imaging procedure. An example would be the case of a patient who
wears a maxillary denture and has natural mandibular teeth who
may be instructed to keep the denture in its place during the
exposure of periapical images of the mandibular teeth. To provide
more diagnostic images, the denture which acts to stabilize the bite
block should be used with the beam alignment devices.

 Complete denture

There are two components parts which constitute a complete denture: 1-a base
material and 2-denture teeth. A typical denture base is composed of acrylic
whereas denture teeth may be composed of porcelain or even acrylic. (Fig.24)
The typical denture base appears as overfaint radiopacity on dental image or
even, in some cases, may not be seen at all, however the denture teeth vary in
appearance where porcelain teeth appear radiopaque and resemble the
radiopacity of dentine. Acrylic (plastic) teeth which lack density, appear
radiolucent or faintly radiopaque.
  Removable partial denture

Different materials can be used to construct a removable partial denture, such as

metal, a combination of metals and acrylic and all acrylic. First, the one
constructed of metal gives a radiopaque shape similar to the metal frame work of
the denture. However, the combined partial denture appears densely radiopaque
in the areas where metal is present and slightly radiopaque where acrylic is
present. Moreover, the denture that is constructed totally from acrylic appears
with wrought. Porcelain or acrylic teeth can be used where the porcelain
appearance is radiopaque near to the radiodensity of dentin whereas the acrylic
teeth appear radiopaque. (Fig.25) (Fig.26)

4) Material used in orthodontics

Orthodontics bands, wires and brackets can be seen on dental image where each
one has different raiopacity than the others.

5) Material used in oral surgery

 Implants: lately, implants are being used more than before. Different
sizes and shapes are present according to its use. An example of
radiopaque implant is the endosteel that is made of metal. (Fig.27)
 Bone grafts: two important factors should be present for implants to
be successful which are, the grafting material that must encourage
osseointegration and the bone’s volume that should hold the implant
properly. (Fig.28)
 6) Fracture stabilizing material

Many materials are used to stabilize fractures in the maxillary on mandibular

bone such as metal plates and splints, suture wires, bone screws and stabilizing
arches. All these materials appear radiopaque but with different shape and sizes.
(Fig.29)

Fig.(29): wires used to repair mandibular bone fracture.

Fig.(22): different materials indicated above from 1 to 8.

Fig.(23): silver points.

Fig.(24):maxillary complete denture with mandibular implant over denture.

Fig.(25): Distal extension mandibular

removable partial denture with implant
support

Fig.(26): IMPLANT SUPPORTED & RETAINED

REMOVABLE PARTIAL DENTURE.

Fig.(27): bone graft between the mandibular

second premolar and first molar.
vi
III. Foreign objects

1) Jewelry:
 Earrings: metal earrings usually appear on extra oral image as
a dense radiopaque bode that have different shape and size.
Plastic earrings containing metal clips or posts may also be
seen by dental imaging. However, artifacts that are caused by
radiodense objects can make the image nondiagnostic by
hiding some info about bones and teeth. (Fig.25)
 Necklace: appears as a radiopacity on the extraoral image.
(Fig.26)
 Nose jewelry: detectable by extraoral and intraoral images. It
appears radiopaque on dental images.(Fig.27)

2) Eyeglasses:
Extraoral and intaoral images may show eyeglasses. There eyeglasses
composed of metal frames are seen radiopaque on there dental
imaging.

3) Miscellaneous objects:
 Napkin chain: the napkin chain is usually seen radiopaque on
extraoral imaging.
 Hearing aids: medical devices used by patients suffering from
difficulty of hearing. These devices may contain metallic
frames, which should be removed before performing any oral
imaging. (Fig.28)
 Shrapnel: metal fragments embedded in both the oral and
maxillofacial region after being exposed to a gunshot. These
metal fragments are seen radiopaque on dental imaging.
(Fig.29)
Fig.(28): earrings cause artifacts in panoramic view.

Fig.(29): radiopaque image of necklace appearing in the mandibular region.

Fig.(25):radiopaque nose jewelry.

Fig.(26): hearing aid without ghost (red arrow) and with ghost (green arrow).

Fig.(27): shrapnel used to restore maxillary bones.

Conclusion
We can conclude that each material used in restorative dentistry has its own radiodensity
appearance on dental images, that is important to prognose, diagnose and treat. So its
mandatory to fabricate materials having different radiodensity than the oral stuctures,
otherwise we can’t detect the dental problems.
Comparison of radiodensity between different materials.
i Skartveit L1, Halse A.Radiopacity of glass ionomer materials.J Oral Rehabil. 1996 Jan;23(1):1-4.

ii Hosney S, Kandil M, El-Mowafy O.Radiopacity of Nonmetallic CAD/CAM Restorative Blocks.Int J Prosthodont. 2016 May-Jun;29(3):271-3.

iii Soares CJ, Rosatto C, Carvalho VF, Bicalho AA, Henriques J, Faria-E-Silva AL. Radiopacity and Porosity of Bulk-fill and Conventional Composite Posterior Restorations-Digital X-ray Analysis. Oper

Dent. 2017 Oct 4. 

iv Raitz R1, Moruzzi PD2, Vieira G3, Fenyo-Pereira M4. Radiopacity of 28 Composite Resins for Teeth Restorations. J Contemp Dent Pract. 2016 Feb 1;17(2):136-42.

v Pette GA1, Ganeles J, Norkin FJ. Radiographic appearance of commonly used cements in implant dentistry. Int J Periodontics Restorative Dent. 2013 Jan-Feb;33(1):61-8.

vi Pinar Gul, Fatma Çaglayan,1 Nilgün Akgul, and Hayati Murat Akgul1. Comparison of radiopacity of different composite resins. J Conserv Dent. 2017 Jan-Feb; 20(1): 17–20.

Dental Radiography, Principles And Techniques Elsevier Health Sciences. Author: Lannucci J. Howerton L.