roent lec feb5
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Principles of Radiologic
Interpretation Accdg to White
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Objective
• To provide a step-by-step, analyticprocess that can be applied to
the interpretation of diagnosticimages
• To equip the reader with a
systematic method of imageanalysis
•
• Proficiency comes only with
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Why take a radiograph?
• If it will be useful and will affectthe treatment plan
• Re: (ICRP) Basic Principles of radiation protection: JO D
•
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Acquiring appropriatediagnostic images
• Asses the Quality of the diagnosticimage
§ Is the image distorted?§ Is the image too dark? Or too light?
§ A thorough knowledge of all possibleimage distortions is a prerequisite.
• Number and type of available images§ As indicated by the clinical examination
§ Interpretation may suggest the need foradditional imaging or views.
§ May suggest need also for images of
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Ideal viewing conditions:
1.Reduced ambient light.
2. The radiographs should be
mounted in a film mount/holder.
3.Light on viewing box should be of
equal intensity across theviewing surface.
4. The size of the viewbox should
accommodate the size of the
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Use of opaque mask (dark surround):If the viewer is much larger than the film
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Use of opaque mask (darksurround):
If the viewer is much larger than thefilm
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5.Intense light may be needed toevaluate dark areas.
6.A magnifying glass allows detailedexamination of small regions of the film.
•
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Systematic Radiographic
Examinations – Important for clinicians to establish
a systematic approach to viewing
and analyzing images— – Helps ensure recognition and
collection of all the informationcontained in the image and in
turn improves the accuracy of theinterpretation
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Analysis of Intraosseous
Lesions
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Step 1 Localize the
abnormality• Determine:
– If localized, or generalized
– The Epicenter• Point of origin (relative to the surrounding
structure) – In bone or soft tissue
– Above or below the IAN canal
– In or outside the IAN canal
– Inside or outside the tooth follicle
– At a tooth root apex
•
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Generalized
• all osseous structures of themaxillofacial region –
• consider metabolic or endocrinedisorders
• Both jaws, cranial vault, long
bones, etc•
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Localized
• – decide if
• Localized to the mandible (whichstructure) – Anterior - ramus - condylar
– Body - angle - coronoid• Localized to the maxilla
– Anterior - posterior
• unilateral or bilateral – Bilateral – may be normal anatomicvariations
– Unilateral –may be abnormal conditions
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Epicenter
• Point of origin (relative to thesurrounding structure) – In bone or soft tissue
– Above or below the IAN canal
– In or outside the IAN canal
– Inside or outside the tooth follicle – At a tooth root apex
•
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– Point of origin – if can bepinpointed, can indicate the
tissue type that compose theabnormality• If epicenter is coronal to the tooth
probably of odontogenicepithelium
• If above the inferior alveolar canallikely of odontogenic tissue
• If below the IAC unlikelyodontogenic tissue
•If within IAC likely neural or
vascular in nature
• If in condylar region likelycartilaginous or considerosteochondrosarcomas
• If within maxi antrum likely non
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Single or multifocal
– List of multifocalabnormalitiesshort
•
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Size
– In centimeters
– Or describing the boundaries
– E.g dentigerous cyst is often larger
than a hyperplastic follicle•
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Step 2
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Step 2Assess the Periphery and
Shape• Well defined or ill-defined? Shape?• Well defined
– If an imaginary pencil can drawconfidently the limits of the lesion
– Some small regions may be ill-defined(may be due to shape or direction of beam
– Punched out– sharp boundary, like by a paperpuncher
• Surrounding bone has normal appearance up tothe edge of the lesion
– Corticated margin- thin, fairly uniformradiopaque line of reactive bone at the periphery ;e.g. cysts
– Sclerotic margin – widen radiopaque border of reactive bone usually not uniform in width
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• Ill-defined borders
– Blending border gradual
transition between normal-appearing bone trabeculae
• Focus on trabeculae not on marrowspaces
• Eg sclerosing osteitis or fibrousdysplasia
– Invasive border associated with
rapid growth, seen usu in
malignant tumors
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• Shape, e.g.
– Circular or fluid-filled shape• Like an inflated balloon
– Scalloped shape• Series of contiguous arcs or
semicircles
• May reflect the mechanism of growth
• Seen in: cysts, cystic like lesions,some tumors
• Sometimes referred to asmultilocular**
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Analyze the Internal
Structure• Classified as: totally radiolucent e.g cysts• totally radiopaque e.g osteomas• radiolucent-radiopaque lesions
• Radiopacity may be within, in front, or
behind the lesion• List of materials from the mostradiolucent to the most radiopaque – Air, fat, and gas
– Fluid
– Soft tissue – Bone marrow
– Trabecular bone
– Cortical bone and dentin
– Enamel
– metal
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• Mixed density lesions:§ Varying trabecular patterns
different from normal bone§ Fibrous dysplasia greater innumber, shorter and randomlyoriented (not aligned in responseto stress) orange-peel or
ground glass appearance§ Stim of new bone formation
Thick trabeculae moreradiopaque
§ Septa – residual bone organizedinto long strands or walls
§ Septa divide into at least 2compartments = multilocular
§ “soap-bubble” appearance–
ameloblastoma
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§ Dystrophic calcifications§ Calci in damaged tissues
§ Eg calcified lymph nodes, appear asdense, cauliflowerlike masses
§ Cementum§ Homogenous, dense, amorphous
structure sometimes organizedinto round or oval shapes
§ Tooth structure§ Knowledge of densities of enamel,
dentin, cementum and pulp
•
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Step 4
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Step 4Analyze the Effects of the
Lesion on SurroundingStructures• Gen: displacement, resorption, etc
• Teeth, Lamina dura, periodontal
membrane space – Tooth displacement in slower
growing, space occupying lesions• Direction of epicenter impt:
– Above the crown ot tooth :displaces apically (follicular cysts,odontomas
– Start in the ramus cherubism ,
push teeth in an anterior direction
–
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• Widening of PL –Observe whether: uniform or
irregular
– Presence or absence of lamina dura
•
• Resorption –Usually more chronic andslower growing lesions
– From chronic inflammation
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• Surrounding bone density andtrabecular pattern – Presence of reactive bone (sclerotic or
corticated)
– Suggests benign growth
•
• Inferior alveolar nerve canal and mentalforamen – Superior displacement of IAC fibrous
dysplasia
– Widening of canal with maintainedcortical boundary benign lesionneural/vascular in origin
– Irregular widening with cortical
destructionàMALIGNANT NEOPLASM
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• Outer cortical bone and periostealreactions
– Cortex may remodel in response to alesion
– Slowly growing lesion new bone
formation, may maintain outer corticalplate
– Fast growing lesion outer cortical plate
may be missing
– Onion-skin type of pattern exudate
lifts off the cortical plate and then
deposits new bone• Seen more in inflammatory lesions than
malignant
– Spiculated new bone formed at right
angles to outer cortical plate•
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Step 5
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Step 5Formulate a Radiographic
Interpretation
• Decision 1: Normal vs Abnormal
• Decision 2 : Developmental vsAcquired
• Decision 3: Classification
• Decision 4: Ways to proceed• The Radiographic report
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Decision 1:
Normal vs Abnormal• Needs in-depth knowledge of
normal anatomy
Decision 2:
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Decision 2:Developmental vs.
Acquired• Analyze the location, shape,
periphery, internal structure, and
effects on surrounding tissues• E.g. When presented with tooth
with short roots, ask: “Did the
tooth develop a short root, orwas the root at one time of normal length?”
•
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Decision 3;
Classification• Select the most likely
developmental or acquired
abnormality• Rule out the more common
lesions: inflammatory or trauma,
etc• Bring clinical information into
interpretation: patient historyand clinical signs and symptoms
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Decision 4:
Ways to Proceed• Decide if data require further imaging,
treatment, biopsy, or observation of the abnormality (watchful waiting)\
• May make a short list of entities fromone of the divisions of acquiredabnormalities
•
• Radiographic report may be necessaryfor: – Documentation
– Communication with other clinicians
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The Radiographic Report
• Patient and general information\ – Date, address of clinic, referring
clinician’s name, patient’s name, age,
gender, any numerical id
• Imaging procedure – List of imaging procedures taken with
date
– E.g.
• Clinical information – Ag history of present illness, any clinical
examination done prior to radiographicexam
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• Findings (observation) – Composed of an objective, detailed list of
observations, without interpretation,
made from diagnostic images – Use step-by-step analysis of lesion to
ensure completeness
• Radiographic interpretation (or
impression) – Should be shorter, and provides an
interpretation for the precedingobservations.
– One should endeavor to provide adefinitive diagnosis, but if not possible,a short list of possible conditions isacceptable.
– Advice regarding further studies, when
required, may be added.•
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self test
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• D e scrip tio n
• .Lo ca tio n
– ,T h e a b n o rm a lity is sin g u la r a n d u n ila te ra l a n d th e.e p ice n te r lie s co ro n a l to th e m a n d ib u la r first m o la r
• .Pe rip h e ry a n d sh a p e – -T h e le sio n h a s a w e ll d e fin e d cortical b o u n d a ry a n d a
.sph e rical o r ro u n d sha p e T h e p e rip h e ry a lso
.a tta ch e s to th e ce m e n to e n a m e lju n ctio n• .In te rn a l stru ctu re
– .T h e in te rn a l stru ctu re is to ta lly ra d io lu ce n t
• .E ffe cts• ,T h is le sio n h a s d isp la ce d th e first m o la r in a n a p ica l d ire ctio n
w h ich re in fo rce s th e d e cisio n th a t th e o rig in w a s co ro n a l to. ,th is to o th A lso th e le sio n h a s d isp la ce d th e se co n d m o la r
d ista lly a n d th e se co n d - .p re m o la r in a n a n te rio r d ire ctio n A p ica l
re sorp tion o f th e d ista lro ot o f th e seco n d d e cid u o u s m o la r h a s
.occurred
• T h e oc clu sal ra d iog ra p h re ve a ls th a t th e b u cca lco rtica lp la te h a s
, ,ex p an d ed in a sm oo th curve d sha p e an d a th in corticalb ou n d ary.still e x ists
Analysis
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Analysis• .T h e se im a g e s re v e a l a n a b n o rm a l a p p e a ra n ce T h e
co ro n a llo ca tio n o f th e le sio n su g g e sts th a t th e tissu e
m a kin g u p th is a b n o rm a lity p ro b a b ly is d e rive d fro m~ .a co m p o n e n t o fth d e n ta l fo llicle T h e e ffe cts o n th e
su rro u n d in g stru ctu re s in d ica te th a t th is a b n o rm a lity
.is a cq u ire d T h e d isp la ce m e n t a n d re sorp tio n o f
, , ,te e th in ta ct p e rip h e ra lco rte x cu rve d sh a p e a n d
-ra d io lu ce n t in te rn a lstru ctu re a ll in d ica te a slo w, , - ,g ro w in g b e n ig n sp a ce o ccu p y in g le sio n m o st like ly
.in th e cy st ca te g o ry
• O d o n to g e n ic tu m o rs su ch a s a n a m e lo b la stic fib ro m a ,,m a y b e co n sid e re d b u t a re le ss like ly b e ca u se o f th e
.sha p e T h e m o st com m o n typ e o f cyst in a fo llicu la r
.lo ca tio n is a fo llicu la r or d e n tig e ro u s cy st
O d o n to g e n ic ke ra to cy sts o cca sio n a lly a re se e n in th is
,lo ca tio n b u t th e to o th re sorp tio n a n d d e g re e o f
e xp a n sio n a re n o t ch a ra cte ristic o f th a t p a th o lo g ic
.co n d itio n
• ,T h e re fo re th e fin a lin te rp re ta tio n is a fo llicu la r cyst w ith
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END
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Self Test
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See pics
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