DENT5102, Spring, 2007
Unit2. Restorative Materials
 Unit3. Dental Caries
 Unit5. Periodontal and Periapical
 Unit6. General Principles of Interpretation
in Osseous Structures
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DENT5102 quiz #1 is posted at the
following web address:
http://www1.umn.edu/dental/courses/dent_5
102/Quiz1/quiz07.html.
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Restorative Materials
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According to radiographic density
beginning with most radiopaque
Group I. Gold alloys, amalgam,silver
Gr.II. Gutta percha, zinc oxyphosphate or
other base materials, composite with
opacifier, rubber base impression material,
calcium hydroxide with opacifier
Gr.III. Porcelain
Restorative Materials (Cont.)
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Gr. IV. Radiolucent. Calcium hydroxide,
composite, resin
Dental Caries
Severity
 1st degree (early, incipient, enamel only)
 2nd degree (moderate, to DEJ)
 3rd degree (advanced, into dentin)
 4th degree (extensive, extending to pulp)
Caries Progression
Dental Caries (Cont.)
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Location
Occlusal, incisal
Lingual, palatal
Buccal, facial
Proximal (mesial, distal)
Cemental (root)
Recurrent
Dental Caries
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Most common location for proximal caries:
just apical to the contact area.Enamel
caries is usually triangular in shape,
occasionally rounded.
Radiographically, occlusal caries can be
seen only when it is in dentin (3rd degree).
Incipient Caries
Dental Caries (Cont.)
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Cemental (root)
Dental Caries (Cont.)
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Recurrent
Recurrent Caries
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Caries immediately next to a restoration
Inadequate margins or excavation
Metallic restorations often hide
Clinical examination
Dental Caries (Cont.)
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Adumbrasion (cervical radiolucency,
cervical burnout).
Adumbration
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Between CEJ and alveolar crest
Diffuse radiolucency
Ill-defined borders
Presence of the edge of root
Clinical evaluation
Caries: Xerostomia
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Therapeutic radiation
Sjogren’s syndrome
Caries begins at cervical region
Extensive decay
Periodontal And Periapical
Diseases
Periodontal Disease
Usefulness of Radiographs
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Amount of bone present
Condition of alveolar crest
Bone loss in furcation areas
Width of periodontal ligament
Local factors: calculus, overhanging
restorations
Crown/root ratio
Limitations of Radiographs
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No indication of morphology of bony
defects
No indication of successful management
No indication of hard/soft tissue
relationship, I.e., depth of pockets
Normal Alveolar Crest
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1.0-1.5 mm apical to
cemento-enamel junction
Parallel to line joining the
CEJ of adjoining teeth
Smooth
Continuation of lamina
dura, has the same
radiopacity
Severity or Extent of Bone Loss
Evidence of Early Periodontitis
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Localized erosion of crest of bone
Blunting of crest- anterior teeth
Loss of sharp angle between lamina dura
and crest
Widening of pdl near crest
Local Factors
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Calculus
Overhanging restorations
Poor restoration contours
Calculus
Calculus
Overhanging Restoration
Buccal VS Lingual Bone Loss
Direction Of Bone Loss
Horizontal Bone Loss:
Crest of bone is parallel to CEJ line
between adjoining teeth. The remaining
bone is still horizontal but may be
positioned apically.
Direction Of Bone Loss
Vertical bone loss
Crest of remaining bone is not parallel to the
CEJ line between adjoining teeth ( displays
an oblique angulation to the CEJ line )
Bone Loss In Bifurcation/trifurcation
Areas
Bitewing Radiographs Most Reliable
For Crestal Bone Evaluation
Generalized Periodontal Disease
Juvenile Periodontitis
(Early-onset Periodontitis, Rapidly Progressing Periodontitis)
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Occurs in healthy individuals between
puberty and age 25
Amount of bone loss is not consistent with
local factors and oral Hygiene habits. Rate
of bone loss is 3-4 times faster than in
typical periodontitis
Juvenile Periodontitis(cont.)
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Typically affects crestal bone of first
molars and incisors. Eventually affects
greater # of teeth.
Bone loss is progressive and frequently
bilaterally symmetrical. Many teeth show
vertical bone loss.
Host neutrophil dysfunction has been
demonstrated by several investigators.
Papillon-Lefevre Syndrome
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Autosomal recessive trait
Hyperkeratosis of palms and soles
Occasional keratosis of other skin
surfaces
Calcification in falx cerebri
Severe destruction of alveolar bone
involving all deciduous and perm. teeth
Exfoliation of teeth
Langerhans’ Cell Histiocytosis
(Histiocytosis X)
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Complex of three diseases:
Eosinophilic granuloma (usually solitary)
Hand-Schuller-Christian disease
Letterer-Siwe disease
Due to abnormal proliferation of
Langerhans’ cells or their precursors
Eosinophilic Granuloma of Bone
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Most common in children and young
adults
Usually single radiolucency
Skull, mandible, vertebra and long bones
commonly involved
Painful, mobile teeth and gingival lesions
Hand-Schuller-Christian Disease
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Most cases reported in children under 10 years.
Has been reported in older individuals
Skeletal and soft tissues may be involved
Classic triad of symptoms:
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“punched out” destructive bone lesions
unilateral or bilateral exophthalmos
diabetes insipidus
Complete triad occurs in 25% of patients
Hand-Schuller-Christian (Cont.)
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Oral manifestations include:
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loose teeth
exfoliated teeth
gingivitis
loss of alveolar bone / advanced
periodontitis
Sharply outlined multiple radiolucent
lesions in skull, jaws and other bones
Letterer-Siwe Disease
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Acute, disseminated form of disease
Usually occurs before age 3. Most patients die
Involves several bones and organs
Skin rash
Intermittent fever, enlargement of liver and
spleen, lymphadenopathy common
Destructive radiolucencies in jaws
Loosening and premature loss of teeth
Hand-Schuller-Christian Disease
Hand-Schuller-Christian Disease
Other Diseases Influencing Course
Of Periodontal Disease
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Diabetes mellitus
Leukemia
Periapical Inflamatory Lesions
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Bone destruction around
apex of tooth, mostly
secondary to pulp
exposure due to caries or
trauma.
Bacterial invasion of pulp
produces toxic
metabolites which escape
to the periapical bone
through apical foramen
and cause inflammation.
The following may occur:
Periapical Inflamatory Lesions
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Periapical granuloma:
Localized mass of
chronic granulation
tissue containing
PMN’s, lymphocytes,
plasma cells.
Periapical Granuloma
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Radiographically,
widening of PDL
or variable size
of periapical
radiolucency
may be present
Periapical Granuloma
Periapical Granuloma
Periapical Abscess
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Periapical abscess:
When pus forms in
the area. It may
develop directly as an
acute process or
develop in a preexisting granuloma.
Radiographically,
appears identical to
granuloma.
Periapical Granuloma Or Abscess
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Can one differentiate between the two on
the basis of radiographs alone?
Periapical Inflamatory Lesions
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Radicular cyst (periapical cyst): Cell rests of
Mallasez (remnants of epithelial root sheath of
Hertwig) proliferate due to inflamatory stimulus
of a granuloma or an abscess and provide the
epithelial lining. What is the definition of a cyst?
“A cyst is an epithelium lined cavity which is
filled with fluid or semi-solid material”. Radicular
cyst is the ONLY cyst related to non-vital pulp.
Periapical Inflamatory Lesions
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Can you definitively differentiate between
a periapical granuloma, abscess or
radicular cyst on the basis of radiograph
alone?
Periapical Inflamatory Lesions(co)
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Condensing osteitis ( chronic sclerosing
osteomyelitis or osteitis). Occasionally, the
reaction to periapical inflammation is
predominantly osteoblastic, I.e., more
sclerotic bone is formed (radiopaque
mass). This usually occurs in children or
young adults when the resistance is high.
Most common location is mandibular 1st
molar.
Condensing Osteitis
(Idiopathic) Osteosclerosis
Osteosclerosis
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How do you differentiate between osteosclerosis
and condensing osteitis?
In osteosclerosis, the pulp is vital. There are no
clinical signs or symptoms. No treatment is
necessary.
Condensing osteitis is secondary to pulp
exposure. Patient is symptomatic. Endodontic
treatment or extraction is indicated.
Calcific Degeneration
(Calcific Metamorphosis)
Secondary to Trauma to the
Tooth
Calcific Degeneration
Calcific Degeneration
Radiographic Evidence Of
Non-vital Teeth
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Widening of apical PDL or periapical
radiolucency ( associated with indication
of pulp exposure)
Discontinuity of lamina dura
Displacement of lamina dura
Condensing osteitis
Calcific degeneration (metamorphosis)
Radiographic indication of pulp exposure
Radiographic Evidence Of
Non-vital Teeth
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Widening of
apical PDL or
periapical
radiolucency (
associated with
indication of pulp
exposure)
Radiographic Evidence Of
Non-vital Teeth
 Discontinuity
lamina dura
of
Radiographic Evidence Of
Non-vital Teeth
Displacement
of lamina
dura
Radiographic Evidence Of
Non-vital Teeth
 Condensing
osteitis
Radiographic Evidence Of
Non-vital Teeth
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Calcific
degeneration
(metamorphosis)
Radiographic Evidence Of
Non-vital Teeth
 Radiographic
indication of
pulp exposure
Periapical Cemental Dysplasia
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Also called Cementoma. Localized alteration in
periapical area. Osseous structure is replaced
by fibrous tissue, cementum-like material,
abnormal bone or combination of these.
Pulp is vital. Patient is asymptomatic. There are
no clinical signs.
No treatment is required.
Mean age is 39 years.
Periapical Cemental Dysplasia
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85% patients are females.
3 times more common in African-americans.
Most commonly seen in mandibular anterior
areas.
May be multiple.
May be bilateral.
Well-defined radiolucency, opacity or mixed.
Periapical Cemental Dysplasia
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Stage I ( Osteolytic stage )
Stage II ( Osteo or cementoblastic stage)
Stage III ( mature stage )
Stage II
Stasge III
Multiple
Apical Scar (Fibrous Scar )
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Variation in healing process. Normally
surgical site fills with blood clot which
organizes and eventually mineralizes and
remodels like surrounding bone.
Occasionally, normal mineralization and
remodelling fails to occur.
Patient is asymptomatic and no treatment
is required.
Apical Scar (Fibrous Scar )
Apical Scar (Fibrous Scar )
Apical Scar (Fibrous Scar )
Periapical Lesions (Bhaskar)
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Periapical granuloma
48%
Radicular cyst
43%
Periapical abscess
1.1%
Residual cyst
3.5%
Apical scar
3.0%
Periapical cemental dysplasia 1.7%
Rare lesions
1.0%
Rare Periapical Lesions(Bhaskar)
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Central giant cell granuloma
Traumatic (simple) bone cyst
Hyperparathyroidism
Periapical Lesions
(LaLonde and Leubke)
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Periapical granuloma
Radicular cyst
Periapical abscess
Other periapical lesions
45.2%
43.8%
3.0%
8.0%
General Principles of Interpretation in
Bone
Relative Radiodensity
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Radiolucency
Radiopacity
Mixed (radiolucency and radiopacity)
Peripheral Outline
Borders Well-defined or Illdefined, Smooth or Ragged?
Expansion of Cortical Plates
Indication of Rate of Growth of
Lesion
Effects on Adjacent Structures
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Resorption of roots of teeth
Mandibular canal ( pain, anesthesia,
paresthesia?)
Location
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Mandible
Maxilla
Anterior
Posterior
Multiple-single
Age
Sex